REPUBLIC OF KENYA

MINISTRY OF HEALTH

MENSTRUAL HYGIENE MANAGEMENT STRATEGY

2019-2024

REPUBLIC OF KENYA

MINISTRY OF HEALTH

MENSTRUAL HYGIENE MANAGEMENT STRATEGY 2019-2024

Table of Contents

Foreword...... v Preface...... vi Acknowledgements...... vii Executive Summary...... viii Acronyms/Abbreviations...... ix Glossary/Definition of Terms...... x Chapter One: Introduction...... 1 Background...... 1 Rationale of the MHM Strategy...... 1 Purpose and Aim of the MHM Strategy...... 2 Strategy Development Process...... 2 Stakeholders Consultation in the Development of the Strategy...... 2 The Menstrual Hygiene Management Framework...... 3 Policy and Strategy Guidelines...... 4 Constitution of Kenya 2010...... 4 National Vision 2030...... 4 National Health Policy 2014-2030...... 4 National Health Sector Strategic and Investment Plan (KHSSIP 2014 -2018)...... 4 Kenya Environmental Sanitation and Hygiene Policy 2016 – 2030...... 5 Basic Education (Amendment) Act...... 5 Kenya School Health Policy 2018...... 5 Other Policy Documents...... 5 Sustainable Development Goals...... 6 United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders with their Commentary (Bangkok Rules)...... 6 The Convention on the Rights of Persons with Disabilities (CRPD)...... 6 The Protocol to the African Charter on People and Human Rights of Women in Africa...... 7 Beijing Declaration and Platform for Action...... 8 Commission on the Status of Women (CSW)...... 8 Chapter Two: Situation Analysis...... 9 Current Situation...... 9 Information, Knowledge and Awareness on Menstruation...... 9 Knowledge of and Access to Menstrual Management Products...... 9 MHM in Learning Institutions...... 10 Safe Disposal of Menstrual Waste...... 10 Analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT)...... 11 Political, Economic, Social, Technology, Environmental and Legal (PESTEL) Analysis...... 12

iii Chapter Three: Goals, Objectives and Strategies...... 15 Vision of the MHM Strategy...... 15 Mission of the MHM Strategy...... 15 Guiding Principles for Implementing the MHM Strategy...... 15 Overall Goal of the MHM Strategy...... 16 Strategic Focus Areas...... 17 Strategic Focus Area 1: Creating an Enabling Environment for MHM...... 17 Strategic Focus Area 2: Breaking the Silence on Menstruation...... 19 Strategic Focus Area 3: Safe and Hygienic Management of MHM...... 21 Strategic Focus Area 4: Safe Disposal of Menstrual Waste...... 23 Strategic Focus Area 5: Monitoring and Evaluation Systems for Accountability and Learning...... 25 Chapter Four: MHM Strategy Implementation Arrangement...... 27 Introduction...... 27 Leadership Alignment to Oversee Implementation of the MHM Policy...... 28 Dissemination of the MHM Strategy...... 28 Implement Formative Technical Interventions on MHM...... 28 Implementation of the Basic Education Ammendment Act...... 29 Strengthen Coordination for MHM at the National and County Levels...... 29 Design and Roll Out a Comprehensive Capacity Development Plan Targeting Actors at all Levels...... 31 MHM Integration into Various Sectors Programmes and Activities...... 31 Roles and Responsibilities of Various Sectors on MHM...... 47 Chapter Five: Monitoring and Evaluation of the MHM Programme...... 51 References...... 52

iv Foreword

The Constitution of Kenya 2010 under article 43 recognizes that the access to water and sanitation is a basic human right. It aims to preserve the dignity of individuals and communities through the promotion of social justice. Kenya vision 2030 envisages that in order to achieve a just and cohesive society that enjoys equitable social development, there is need to ensure favorable health and education outcomes for its citizens are realized in a clean and secure environment. This is in line with ensuring the universal access to adequate water and sanitation targets of the Sustainable Development Goals (SDGs). Menstruating in dignity is part of the fundamental right of girls and women, half of the country’s population. Girls’ ability to manage their menstruation is influenced by broader gender inequities across Kenya and can be hindered by the presence of discriminatory social norms. There may be opportunities to leverage Menstrual Hygiene Management as an entry point to sensitive sexual, early childhood marriages, female genital mutilation (FGM) and reproductive health topics, such as reproductive rights, transactional sex, and teenage pregnancy prevention. Menstrual Hygiene Management (MHM) is a far-reaching and complex issue that needs to be addressed from various sectors: water, sanitation and hygiene, education, health, protection and social and economic aspects. In Kenya, the Kenya Health Policy (2012-2030), the Kenya Environmental Sanitation and Hygiene Policy and Strategy (2016 – 2030), the National Reproductive Health Policy (2007), the Gender Policy in Education (2007) and the National Adolescent Sexual and Reproductive Health Policy (2015) all contain aspects of MHM. Despite the mainstreaming of the MHM issues in existing national policies in different sectors, there has been lack of strategic framework for the policy implementation and clarification of roles and responsibilities of different stakeholders. The Kenya Menstrual Hygiene Management (MHM) Strategy 2019-2024 provides a medium-term framework for both state and non-state actors at National and County levels to implement the Kenya Menstrual Hygiene Policy. It sets out strategic focus areas with the aim of mainstreaming MHM, strengthening partnerships and coordination, development and maintenance of Water sanitation and Hygiene (WASH) infrastructure, strengthening MHM education and awareness, promoting advocacy and resource mobilization, and establishing effective Monitoring and Evaluation systems for MHM. The vision of the strategy is to ensure that women and girls have access to improved Menstrual Hygiene, where safe hygienic behaviour during menstruation is the norm, and where comprehensive menstrual waste management is widely practiced, leading to improved well-being and full realization of life. The strategy is an outcome of recommendations made by the Joint Monitoring Programme (JMP) and one of the priorities of Kenya Environmental Sanitation and Hygiene Policy 2016-2030. The Strategy takes full cognizance of the devolution of most sanitation functions and services to County Governments. This comprehensive strategy enables stakeholders to collectively and effectively improve the situation around MHM in Kenya, thereby ensuring the wellbeing of girls and women, as well as implications for the environment and ultimate gender equality in the country.

Sicily K. Kariuki (Mrs.), EGH Cabinet Secretary Ministry of Health

v Preface

The Kenya Menstrual Hygiene Management (MHM) Strategy marks a milestone in the Country’s movement towards universal access to adequate sanitation and hygiene and a clean and healthy environment in the wake of the new Constitution of Kenya 2010 and the Sustainable Development Goals (SDGs). The Government through the Constitution 2010 and the Kenya Vision 2030, has created an enabling environment for all stakeholders to make their contributions towards our collective aspiration where every Kenyan, including women and girls enjoy high quality of life in a clean, secure and healthy environment. The goal of this Strategy is to address the needs of girls and women and to provide a vehicle to transform the MHM in Kenya, in line with the MHM policy. The Strategy provides both guidelines and an action plan where all the women and girls of Kenya will have access to better MHM options which if widely practiced will lead to a better life for all the women and girls in Kenya. As the issue of MHM requires the investment and partnership from multiple sectors, this Strategy forms the basis of a Sector Wide Approach for MHM where all the stakeholders collectively commit and tackle the current poor MHM and sanitation situation in the country. It also clarifies the roles and responsibilities of different leading stakeholders to deliver results. The Strategy outlines the five strategic focus areas and key interventions to achieve the following five key objectives in the MHM Policy: Policy Objective 1: To establish an enabling legal and regulatory environment for MHM at both national and county levels. Policy Objective 2: To ensure that myths, taboos and stigma around menstruation are addressed by providing women, girls, men and boys access to information on menstruation. Policy Objective 3: To ensure women and girls have access to safe and hygienic menstrual products, services and facilities. Policy Objective 4: To ensure a clean and healthy environment for all Kenyans through appropriate technology choices for menstrual waste management and pollution control. Policy Objective 5: To establish a functionally effective monitoring, evaluation, research and learning framework for MHM in Kenya hence, ensure maximum accountability in policy implementation at all levels. In conclusion, I call upon all likeminded stakeholders to join hands with the Government to ensure that girls and women menstruate with dignity by implementing this Strategy.

Susan N. Mochache, CBS Principal Secretary Ministry of Health

vi Acknowledgement

This Kenya Menstrual Hygiene Management (MHM) Strategy is the result of joint efforts, contributions and guidance of Ministry of Health, Ministry of Education, the Environmental Sanitation and Hygiene Inter agency Coordinating Committee (ESH-ICC), all Technical working groups. Hygiene Promotion Technical working group is acknowledged for its leadership of the Strategy development process. Gratitude for the invaluable contributions of the Consultants, Dr Felix Kioli, Dr Karen Nyagara and Job Wasonga all from Maseno University and their able technical facilitation of the process of development of this Strategy. Many thanks to Jackson Muriithi, Deputy Director, Public Health who provided leadership throughout the entire process, special thanks to Adam Ali, Janet Mule, Benjamin Murkomen, and Ibrahim Basweti. The Ministry also wishes to acknowledge with deep gratitude the contribution of key members of the ESH-ICC and partners including Agnes Makanyi and Maya Igarashi Wood (UNICEF), Samson Shivaji (KEWASNET), Tobias Omufwoko and Mercy Miriti (WAK), Archana Patkar, Virginia Kamowa PhD and Neville Okwaro (WSSCC), Adrian Dongus (AfriPads), Beverly Mademba (WASH UNITED), Irene Gai and Catherine Mwango (KWAHO), and Barnet Walema of Ministry of Education. Special thanks to the Private sector and non-governmental organizations including Afripads, Huru International, Zana Africa, Grow and Know, Ruby cup and Real Relief. Further, the Ministry of Health on behalf of the people of Kenya is grateful to UNICEF and WSSCC for providing financial support to the Strategy development. We recognize members of TC 069-Towels, Medical Textiles and Hygiene products working group under the auspices of Kenya Bureau of Standards for their invaluable input towards this Strategy. Lastly, we highly appreciate all the counties for your contribution to this Strategy during the public participation meetings.

Kepha Ombacho, PhD, FAIPH, MBS Director Public Health Ministry of Health

vii Executive Summary

Menstrual Hygiene Management (MHM) is a multi-dimensional, critical component of sanitation, education, and health. There exists an array of barriers to high-quality Menstrual hygiene management (MHM) across Kenya. It remains particularly challenging for low-income women and girls. Situation analysis reports shows that girls face monthly challenges, with 58% of girls in rural and 53% of girls in urban areas in Kenya unable to afford sanitary pads. An average of 22% of school aged girls reported that they purchase their own sanitary products, which begs the question of who provides the money and what they have exchanged for it. Another study alerting that some impoverished young adolescent girls needed boyfriends to pay for their pads. only 30% of the schools provide sanitary pads for their students and in most instances, these are only for emergencies. Just 36% of rural schools had adequate and private toilets for girls, which could aid in changing their menstrual product. Evidence in Kenya has illustrated the problem girls face, causing them shame and avoidance of school activities. Evidence on the impact of poor menstrual health, on critical outcomes is accruing, showing provision of improved MHM education, infrastructure, and products will improve girls lives. Research studies in Kenya have illustrated safe and effective use of menstrual products, with a reduction in infections and increased ability to engage in school- life. Girls’ ability to manage their menstruation is influenced by broader gender inequities across Kenya and can be hindered by the presence of discriminatory social norms. There may be opportunity to leverage MHM as an entry point to sensitive sexual, early childhood marriages, female genital mutilation (FGM) and reproductive health topics, such as reproductive rights, transactional sex, and teenage pregnancy prevention. Guidance is also required to support the issues and needs of menstruating women in the workplace.

viii Acronyms/Abbreviations

AIDS Acquired Immune Deficiency Syndrome BCC Behaviour Change Communication CBO Community Based Organization CHWS Community Health Workers CRC Child Rights Convention DPS Development Partners EHS Environmental Health and Sanitation FGM Female Genital Mutilation GBV Gender Based Violence GSAEP Global Sanitation and Environmental Programme HIV Human Immunodeficiency Virus ICC Inter Agency Coordinating Committee IEC Information Education and Communication JMP Joint Monitoring Programme KEBS Kenya Bureau of Standards KHSSP Kenya Health Sector Strategic and Investment Plan KIRDI Kenya Industrial Research Development Institute KMHMS Kenya Menstrual Hygiene Management Strategy KWAHO Kenya Water for Health Organization LMIC Low- and Medium-Income Countries M&E Monitoring and Evaluation MDGs Millennium Development Goals MHM Menstrual Hygiene Management MOE Ministry of Education MOH Ministry of Health MTEF Medium Term Expenditure Framework NEMA National Environmental Management Authority NGOs Non-Governmental Organizations NMHMP National Menstrual Hygiene Management Program PESTEL Political, Economic, Social, Technological Environmental and Legal PHOS Public Health Officers SAGAs Semi-Autonomous Government Agencies SDGs Sustainable Development Goals STI Sexually Transmitted Infection SWAP Sector Wide Approach to Planning SWOT Strengths, Weaknesses, Opportunities and Threats TOTS Trainer of Trainees TWG Technical Working Group UNICEF United Nations Children’s Fund UTI Urinary Tract Infections VHC Village Health Committee VIP Ventilated Improved Pit latrine WASH Water, Sanitation and Hygiene WSSCC Water Supply and Sanitation Collaborative Council WATSAN Water and Sanitation WHO World Health Organization

ix Glossary/Definition of Terms

Adolescents: The policy defines these as persons aged between 10 and 19 years. Adolescent girls: Adolescence describes the transitional period between childhood and adulthood, Girls aged 10 to 19 are adolescents. Age Appropriate: The suitability of information and services for females targeted by this policy, generally those between the ages of 13 and 54 years old. Biodegradable; compostable,organic materials: A substance or object that is capable of being decomposed by bacteria or other living organisms and thereby avoiding pollution. Female Friendly Facilities: Menstrual Hygiene Management facilities in public spaces and private households that are designed and maintained in ways that are responsive to specific needs and desires of females. Hygiene: A set of practices associated with the preservation of good health and healthy living. It consists of behaviours related to the safe management of human waste, such as handwashing with soap or the safe disposal of sanitary products. Good hygiene involves keeping oneself and one’s surroundings clean, especially in order to prevent illness or the spread of disease. It therefore infers cleanliness relating to good health. Life Skills Education: A structured program of needs and outcomes based participatory learning that aims to increase positive and adaptive behaviour by assisting individuals to develop and practice psycho-social skills that minimize risk factors and maximize protective factors. Life skills education programs are theory and evidence based, learner-focused,delivered by competent facilitators and are appropriately evaluated to ensure continuous improvement of documented results. Menarche: The first occurrence of menstruation. Menstrual absorbent: A sanitary cloth, napkin, towel or pad is an absorbent item worn by an adolescent girl or woman when she menstruates. The material absorbs the flow of blood from the vagina. Menstrual Health: A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the menstrual process. Menstrual Management Materials and Products: Materials and products including disposable and reusable sanitary pads, tampons, and reusable menstrual cups, clean piece of cotton cloth or cotton wool, are safe and hygienic, absorb or collect blood during menstrual period.

x Chapter One: Introduction

Background Systematic studies as well as focus on Menstrual Hygiene Management (MHM) can be traced back to 2004 during the strong global movement to close the gender gap in education. This movement was based on the Millennium Development Goals (MDGs) and spearheaded by Non-Governmental Organizations (NGOs) together with the private sector in Low- and Middle- Income Countries (LMICs), especially in sub Saharan Africa. Research evidence is building to support policies and strategies to deal with MHM in a systematic manner. Kenya is a signatory to several international and regional human rights treaties and declarations. These include The Convention on the Rights of the Child (CRC) ratified in 1990, Program of Action of the International Conference on Population and Development (1994), The Platform for Action developed at the United Nations Fourth World Conference on Women (1995), the MDGs approved by the World Summit on Sustainable Development (2000), as well as the Maputo Plan of Action (2007-2010). These instruments reiterate that, all human rights, civil; cultural, economic, political and social, including the right to development, are universal, indivisible, interdependent and interrelated. The Vienna Declaration and Programs of Action adopted by the World Conference on Human Rights (1993), reaffirmed that human rights of women and girls are an inalienable, integral and indivisible part of universal human rights. It operates inside the mandate of ensuring favorable health and education outcomes for its citizens, in order to achieve a just and cohesive society enjoying equitable social development, in a clean and secure environment as enshrined in Kenya Vision 2030 blueprint. Nationally, the Constitution of Kenya 2010 recognizes the protection of human rights and aims to preserve the dignity of individuals and communities through the promotion of social justice. In addition, the National Reproductive Health Policy (2007), the Gender Policy in Education (2007), the Kenya Health Policy (2012-2030), the National Adolescent Sexual and Reproductive Health Policy (2015) and the Kenya Environmental Sanitation and Hygiene Policy and Strategy (2016 – 2030) all contain aspects of Menstrual Hygiene Management. MHM is a far-reaching and complex issue that can be addressed from various aspects: hygiene, sanitation, education, social and economic. A comprehensive strategy usable by actors in policy implementation will ensure the wellbeing of half of the country’s population, as well as implications for the environment and ultimate gender equality in the country.

Rationale of the MHM Strategy The basic level of access to better menstrual hygiene management practices in Kenya, although higher in terms of coverage than many other sub-Saharan nations, is generally of poor standards. This situation is further contributed by low levels of hygienic behavior, poor and inadequate sanitation facilities as well as skewed access to recommended sanitary products. This has resulted in high levels of hygiene related infections. In urban centers, the inability to properly dispose of sanitary waste has resulted in a constant eyesore and health hazard. Levels of sanitation at schools leave much to be desired ranging from the perspective of maintenance and availability of facilities to generally poor level of health and hygiene education in the curriculum.

1 The water and sanitation sector is key in implementing menstrual hygiene management activities. However, efforts to invest adequately in Menstrual Hygiene Management inthe Sanitation sector have been frustrated by lack of a strategic framework. There is also ambiguity over roles and responsibilities in the sector, and a disconnect between existing policies and legal instruments that deal with sanitation and menstrual hygiene management in passing. Key stakeholders in the sector do not feel obliged to provide the required Menstrual Hygiene Management services because there is inadequate capacity at all levels to plan, design and implement Menstrual Hygiene Management Programmes that integrate infrastructure development and hygiene education, while addressing other cross-cutting issues such as gender as well as the access to affordable recommended menstrual hygiene management products. The development of the Kenya Menstrual Hygiene Management Strategy was one of the priority areas that the Joint Monitoring Program (JMP) recommended for immediate action. The immediate development of a NMHM strategy is also consistent with the prioritization of Kenya Environmental Sanitation and Hygiene Policy 2016 – 2030.

Purpose and Aim of the MHM Strategy The purpose and aim of the Kenya Menstrual Hygiene Management Strategy is to answer the needs outlined above and to provide a vehicle to transform the Menstrual Hygiene Management in Kenya. As the vision points out below, it is to provide both guidelines and an action plan where all the women and girls of Kenya will have access to better menstrual hygiene management options which if widely practiced will lead to a better life for all the women and girls in Kenya. The strategy by providing guidelines and an action plan, will form the basis of a Sector Wide Approach (SWAP) for MHM. Partners committed in making significant contributions to the development of the country can commit funds and other resources to tackle the current poor menstrual hygiene management and sanitation situation in Kenya.

Strategy Development Process

Stakeholders Consultation in the Development of the Strategy The development of this strategy involved a variety of participatory methods and a wider consultative process. It encompassed intensive task coordination and management through a MHM-led Working Group, established under the framework of the Environmental Sanitation and Hygiene Interagency Coordinating committee. In addition, it provided an in-depth review of the national and international references. Stakeholder consultations were carried out with relevant government agencies, non-governmental organizations, and research organizations. Situation analysis to inform development of this strategy was conducted in various geographical locations and cultural contexts in Kenya. and focus group discussions (FGDs) were held with Primary and Secondary school children (boys and girls), whereas Key Informant Interviews (KIIs) were held for the teachers, Officials of Division of Environmental Health at the Ministry of health and NGOs in water hygiene and sanitation sector in country.

2 The Menstrual Hygiene Management Framework The Menstrual Hygiene Management Strategy for Kenya has been developed on the basis of Menstrual Hygiene Management Framework with four components listed as follows: Access to hardware, Hygiene promotion, Access to affordable menstrual hygiene management products and an Enabling environment. An integrated program with all four components is the ideal for Menstrual Hygiene Management.

Improved Health and Well-being

Enabling Environment and Institutional Strengthening Policy Improvement Community Involvement and Participation Institutionalize Legal and Regulatory Framework for MHM Human Resource Capacity Development Financial Investment

Access and Safe Disposal of Measuring informed choice used menstrual MHM, Evidence on safe and materials and Generation hygienic materials products/ Safe Re- & Use of Data and products and use of menstrual access to materials materials to manage menstruation

Access to Menstrual Information/ Education

Framework for Improvement of Menstrual Hygiene Management

3 Policy and Strategy Guidelines This strategy has close linkage to the following policies, strategies and action plans and implementation of this will lead to significant gains in those interventions and activities highlighted in these documents: Constitution of Kenya 2010 In 2010, the Constitution of Kenya included economic, social, and cultural rights for the first time in its Bill of Rights. The right to the “highest attainable standard of health, which includes the right to health care services including reproductive health care” is guaranteed for all Kenyans. The Constitution promotes the right to health care for specific groups as seen in Article 53 for children’s rights and Article 54 for Persons with disabilities. The underlying determinants of the right to health are also guaranteed in article 43(1) (b-f) and include the right to adequate housing, right to adequate food, clean safe water, social security and to education. Additionally, the Constitution has committed itself to promoting and ensuring respect for “human dignity, equity, social justice, inclusiveness, equality, human rights, non-discrimination and protection of the marginalized” as a national value and principle of governance. The Constitution provides for equality and freedom from discrimination. It specifically obligates the state to ensure that no direct or indirect discrimination is experienced by any Kenyan or any group.

National Vision 2030 Vision 2030 is the long-term development blueprint for the country, aiming to transform Kenya into a “globally competitive and prosperous and newly industrialized middle-income country providing a high quality of life to all its citizens in a clean and secure environment by 2030”1. Health is one of the components of delivering the Vision’s Social Pillar, given the key role it plays in maintaining the healthy and skilled workforce necessary to drive the economy. The goal aims to develop a population that is healthy, productive and able to fully participate in and contribute to other sectors of the economy.

National Health Policy 2014-2030 The goal of the Kenya Health Policy 2014–2030 is attainment of the highest standard of health in a manner responsive to the needs of the Kenya population (Ministry of Health, 2014). Kenya’s health policy framework future direction 2012 -2030 introduces new ways of managing the health sector as it seeks to provide health services to all. It also creates opportunities to upscale support to the health sector’s requirements for the provision of adequate services and facilities for the management of menstrual hygiene which shall be considered a basic right. The rights and freedoms granted to each citizen of Kenya shall be upheld in this context.

National Health Sector Strategic and Investment Plan (KHSSIP 2014 -2018) The goal of the National Health Sector Strategic and Investment Plan (KHSSIP 2014 -2018) is to reduce health inequalities and to reverse the downward trend in health-related outcomes and impact indicators. The key focus areas in the health sector are, “Access, equity, quality, capacity and institutional framework” to be achieved through a devolution approach through allocation of resources and the responsibility of delivery of healthcare which empowers Kenyan households and social groups to have an active role in maintaining and managing their health (Ministry of Health, 2012).”

1 Government of the Republic of Kenya (2007) Kenya Vision 2030. http://vision2030.go.ke/inc/uploads/2018/05/Vi- sion-2030-Popular-Version.pdf. Pg 2

4 Kenya Environmental Sanitation and Hygiene Policy 2016 – 2030 The Kenya Environmental Sanitation and Hygiene Policy (2016–2030), section 5.4.9 is explicit on the urgent need to promote good menstrual health and management. Improved MHM and appropriate facilities in public places provide menstruating women and girls with the security, privacy and dignity they need and want during menses. This policy highlights the need for safe collection and disposal of menstrual waste with particular attention to women and girls in humanitarian and emergency situations.

Basic Education (Amendment) Act The Basic Education (Amendment) Act No. 17 of 2017 addresses the importance of access to menstrual products for girls in learning institutions, and the safe disposal thereof. The document states that the government shall “provide free sufficient and quality sanitary towels to every girl child registered and enrolled in a public basic education institution who has reached puberty and provide a safe and environmentally sound mechanism for disposal of the sanitary towels”2.

Kenya School Health Policy 2018 The Kenya School Health Policy (2018) states that “Menstrual Hygiene Management (MHM), is a crucial element of the School Health Policy, being important for dignity, gender equality and the human rights of women and girls. This policy recognizes that women and girls who experience challenges with MHM will also experience negative effects on multiple areas of life; relevant to the human rights of women and girls, including in particular the rights to health, work and education, as well as gender equality”3. The school health policy outlines clear action points, indicators and objectives to achieve comprehensive MHM across schools in Kenya.

Other Policy Documents There are other pieces of enabling legislation that promotes various rights to health including sexual and reproductive health in Kenya. These include: The Health Act (2017); Public Health Act Cap 242; (revised 2012) HIV and AIDs Prevention and Control Act (2006); Persons with Disabilities Act (2003); the Sexual Offences Act (2011); the Prohibition Female Genital Mutilation Act no.32 (2012); and National Gender and Equality Commission Act (2012). The Kenya National Policy on Gender and Development (NPGD) 2000, seeks to institutionalize gender as a key concept in development. The revised policy shifts from the 2000 Women in Development approach to Gender and Development with a strong emphasis that gender responsiveness be mandatory for all Ministries, Departments and Agencies of government (MDAs). Acknowledging the decentralized infrastructure for implementing development programs in Kenya, the policy emphasizes that gender mainstreaming requirements for all MDAs provide a clear linkage with the major national gender policy initiatives. The MHM Strategy is cognizant of further provisions in the Gender Policy in Education (2007), Kenya Health Policy (2012- 2030), National Adolescent Sexual and Reproductive Health Policy (2015).

2 The Basic Education (Amendment) Act No. 17 of 2017, p. 337. 3 Kenya School Health Policy 2018, p.17

5 Sustainable Development Goals While menstrual hygiene management does not constitute a specific (sub-)goal of the sustainable development goals, the deliverables of the SDGs are directly or indirectly impacted by addressing the MHM needs of girls and women. These overarching SDGs are: Goal 3 – Ensure healthy lives and promote wellbeing for all at all ages. Goal 4 – Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all. ● 4.5 By 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities, indigenous peoples and children in vulnerable situations. Goal 5 – Achieve gender equality and empower all women and girls. ● 5.1 End all forms of discrimination against all women and girls everywhere. Goal 6 – Ensure access to water and sanitation for all. ● 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations. Goal 8 – Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all. Goal 12 – Ensure sustainable consumption and production patterns. ● 12.5 By 2030, substantially reduce waste generation through prevention, reduction, recycling and reuse.

United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders with their Commentary (Bangkok Rules) Rule 5 on Personal Hygiene states that: “The accommodation of women prisoners shall have facilities and materials required to meet women’s specific hygiene needs, including sanitary towels provided free of charge and a regular supply of water to be made available for the personal care of children and women, in particular women involved in cooking and those who are pregnant, breastfeeding or menstruating.”5

The Convention on the Rights of Persons with Disabilities (CRPD)6 The Convention on the Rights of Persons with Disabilities (CRPD), offers the most comprehensive and authoritative set of standards on the rights of people with disabilities. Its fundamental purpose is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity. The CRPD mandates States Parties to recognise that persons with disabilities enjoy legal capacity on an equal basis with others. This means that an individual’s right to decision-making cannot be substituted by decision-making of a third party, but that each individual without exception has the right to make their own choices and to direct their own lives, whether in relation to living arrangements, medical treatment, or family relationships.

5 https://www.unodc.org/documents/justice-and-prison-reform/Bangkok_Rules_ENG_22032015.pdf 6 http://wwda.org.au/wp-content/uploads/2013/12/WWDA_Sub_SenateInquiry_Sterilisation_March2013.pdf

6 Among other things, the CRPD also mandates States Parties to: protect persons with disabilities from violence, exploitation and abuse (including the gender-based aspects of such violations); ensure that persons with disabilities are not subjected to arbitrary or unlawful interference with their privacy and family, including in all matters relating to marriage, family, parenthood and relationships; guarantee persons with disabilities, including children, the right to retain their fertility; take measures to ensure women and girls enjoy the full and equal enjoyment of their human rights; prevent people with disabilities from being subject to torture, or cruel, inhuman or degrading treatment or punishment; prohibit involuntary treatment and involuntary confinement; and, ensure the right of people with disabilities to the highest attainable standard of health without discrimination. This MHM policy recognizes the rights of persons with disabilities as enshrined in the CRPD and the Constitution of Kenya.

The Protocol to the African Charter on People and Human Rights of Women in Africa This regional instrument that adequately protects the rights of women taking into account the cultural specificity of Africa and the special needs of African women will be taken into account while implementing this policy. The charter recognizes that any practice that hinders or endangers the normal growth and affects the physical and psychological development of women and girls should be condemned and eliminated and at the same time it seeks to ensure that the rights of women are promoted, realised and protected in order to enable them to enjoy fully all their human rights.7 The following articles will have a strong bearing on the implementation of this policy: Article 2: Elimination of Discrimination Against Women

This states that “States Parties shall combat all forms of discrimination against women through appropriate legislative, institutional and other measures” Article 3: Right to Dignity

This states that “Every woman shall have the right to dignity inherent in a human being and to the recognition and protection of her human and legal rights.” Article 12: Right to Education and Training

States Parties shall take all appropriate measures to: Section 1 a) eliminate all forms of discrimination against women and guarantee equal opportunity and access in the sphere of education and training. Article 14: Health and Reproductive Rights

This calls upon state Parties to “ensure that the right to health of women, including sexual and reproductive health is respected and promoted” Article 18: Right to a Healthy and Sustainable Environment

This article will inform and govern the inclusion of women in waste management and in this regard, menstrual waste. Section 2 of the Article, calls upon states to ensure the following: a) ensure greater participation of women in the planning, management and preservation of the environment and the sustainable use of natural resources at all levels;

7 https://www.un.org/en/africa/osaa/pdf/au/protocol_rights_women_africa_2003.pdf

7 b) promote research and investment in new and renewable energy sources and appropriate technologies, including information technologies and facilitate women's access to, and participation in their control; c) protect and enable the development of women’s indigenous knowledge systems; d) regulate the management, processing, storage and disposal of domestic waste; e) ensure that proper standards are followed for the storage, transportation and disposal of toxic waste.

Beijing Declaration and Platform for Action8 The Beijing Declaration and Platform of Action recognizes women’s rights as human rights and therefore seeks to ensure the full implementation of the human rights of women and of the girl child as an inalienable, integral and indivisible part of all human rights and fundamental freedoms. Further, the declaration seeks to promote equal access to and equal treatment of women and men in education and health care and enhance women’s sexual and reproductive health as well as education. This policy will take into consideration the spirit of this declaration of taking all necessary measures to eliminate all forms of discrimination against women and the girl child and remove all obstacles to gender equality and the advancement and empowerment of women particularly in the area of Menstrual Hygiene Management in Kenya.

Commission on the Status of Women (CSW)9 The Commission on the Status of Women (CSW) is the principal global intergovernmental body exclusively dedicated to the promotion of gender equality and the empowerment of women. A functional commission of the Economic and Social Council (ECOSOC), it was established by ECOSOC resolution 11(II) of 21 June 1946. The CSW is instrumental in promoting women’s rights, documenting the reality of women’s lives throughout the world, and shaping global standards on gender equality and the empowerment of women. During the 63rd Session the CSW came up with commitments that The Commission recognizes that, despite gains in providing access to education, girls are still more likely than boys to remain excluded from education. It also recognizes that among the gender-specific barriers to girls’ equal enjoyment of their right to education, is the lack of safe and adequate sanitation facilities, including for menstrual hygiene management. Under the Section on Making Infrastructure work for Women and Girls, the CSW gave the following commitment that has a direct bearing on MHM: “Ensure availability and sustainable management of water, as well as access to safe and affordable drinking water and adequate and equitable sanitation and hygiene for all women and girls, as well as for menstrual hygiene management, including for hygiene facilities and services, in homes, schools, temporary shelters for refugees, migrants or people affected by natural disasters, humanitarian emergencies or armed conflict and post-conflict situations and in all other public and private spaces; take measures to reduce the time spent by women and girls on collecting household water; address the negative impact of inadequate and inequitable access to drinking water and to sanitation and energy services on the access of girls to education; and promote women’s full, effective and equal participation in decision-making on water and sanitation.”

8 https://www.un.org/en/events/pastevents/pdfs/Beijing_Declaration_and_Platform_for_Action.pdf 9 https://www.unwomen.org/en/csw

8 Chapter Two: Situation Analysis

Current Situation Menstrual health is a multi-sectoral issue that forms a critical component of sanitation, education, health, decent work and well-being. Studies conducted in low and middle-income countries indicate that women and girls face several challenges relating to information access about menstruation, affordable and appropriate sanitary products, poor sanitation facilities and lack of proper avenues for disposal of menstrual waste (Sommer et al., 2016; Chandra-Mouli & Patel, 2017). This situation is compounded by taboos and cultural practices that accompany the discussion of sexuality in general and menstruation in particular. The ‘culture of silence’ surrounding the topic of MHM stifles women and girls’ ability to express their sexuality and hinders their participation which is a fundamental human rights principle. Women’s and girls’ voices are indispensable to ensuring that their needs are understood and prioritized. This includes material and privacy requirements for Menstrual Hygiene Management. Policies and special measures need to be adopted to tackle gender inequalities in practice and strengthen women’s voice and participation.

Information, Knowledge and Awareness on Menstruation A situation analysis study commissioned by the Ministry of Health (2016) as a step towards developing an MHM policy revealed that the median age for menarche in Kenya stands at 14.4 years. Information about menstruation is received from mothers, 87.7% and from teachers, 15.5%. However, while parents remain the primary source of information, they are mostly concerned with ensuring that their daughters avoid child and teenage pregnancy. Minimal attention is given to Menstrual Health and Hygiene with adolescent girls and boys reporting that it is shameful to discuss menstruation. The myths perpetuated by this silence and stigma results in shame and confusion, poor hygiene during the menstrual period, incidence of urinary tract and vaginal infections, absenteeism from school and work and a sense of poor self-worth that persists long after menstrual period. Almost half of Kenyan women and girls interviewed believed that it was not correct to talk about or discuss menstruation and more than half believed that menstrual blood contained harmful substances.

Knowledge of and Access to Menstrual Management Products Currently, there are broad variations in what products females use, the most common materials are store bought sanitary products. According to the situational analysis, 46% of the population in rural areas use disposable sanitary pads compared to 65% in urban areas, while 6%in rural areas use reusable sanitary pads compared to 3% in urban areas. The study further showed that 20% in rural areas use either toilet paper, pieces of blankets or cloth or all other natural materials compared to 19% in urban areas. The study further showed that 54% of Kenyan girls faced challenges with access to MHM products, with 22% of school-going girls indicating that they purchased their own sanitary products. This raises troubling questions of how they are able to afford these products.

9 Studies have indicated that up to 65% of women and girls in Kenya cannot afford sanitary pads (Afri-Can, 2015). Since commercial sanitary products are highly valued, some girls without access will resort to (or are coerced into) having sex to pay for sanitary products. For example, in Western Kenya, 10% of young adolescent girls admitted transactional sex for pads (Phillips- Howard et. al., 2015). If women and girls are well informed about pre-menarche, understand their bodies, can access the correct information without shame, they will be able to choose products based on their needs and economic capacity. They will also create demand for the kinds of products they would prefer and drive the market to invest in linked research and development, packaging or better affordability.

MHM in Learning Institutions There are over 28, 362 primary and 8, 625 secondary schools in Kenya respectively with a student population of over 11,869,138 learners (MOEST, 2014). Out of this population, there are about 4,059,000 whom are adolescents and are likely facing the challenges related to MHM. Findings of a study done in Western Kenya revealed that WASH conditions in the majority of rural Kenyan primary schools are insufficient for the MHM needs of menstruating girls. It further stated that suboptimal WASH conditions in schools may hinder girls’ ability to concentrate in class, attend school when menstruating, or at worst drop-out of school completely (Alexander, et al., 2014). According to the situational analysis report, in many schools and communities, water and sanitary facilities were found to be a challenge with only 24% reporting adequacy of sanitary facilities. It further showed that 18% of learning institutions had water in the taps near the toilets, as well as hand washing facilities and soap. Most schools, 82% had water closets but did not have running water in the toilets. In terms of sanitary products provision, about 30% of the schools sampled provided sanitary pads for their students, but in most instances the sanitary pads were only provided for emergencies. In many households’ water is ferried from tanks and storage containers, while many urban households have to purchase their water from vendors. These statistics give a basic picture of functionality without linked information on cleanliness, lockable doors, lighting and privacy, suitability for washing, changing and safety. Girls report their reluctance to use school toilets and women to usage of toilets while travelling, marketing or at work.

Safe Disposal of Menstrual Waste Disposal of menstrual hygiene products is not only a waste management problem, but a health issue as well. Poor disposal of menstrual products may act as a breeding ground for infections and diseases. Stagnant menstrual blood accumulates bacteria such as E.coli which may cause serious health problems (Plummer, 2017). According to the situational analysis, disposal of sanitary products is carried out in different ways in Kenya, 65% of the rural population dispose their sanitary products in a pit latrine compared to 50% in urban set -ups. Disposal through garbage collectors was 39% in urban and 22% in the rural areas whereas crude burning was 2% in urban and 6% in rural settings. Generally, most schools and families use pit latrines to dispose off the menstrual hygiene products. The study further found that in urban areas, garbage was either collected, 38% or thrown into a rubbish pit 9%. The Kenya Environmental Sanitation and Hygiene Policy 2016 - 2030 explicitly emphasizes on the need to ensure that appropriate mechanisms are put in place for safe collection and disposal of menstrual waste.

10 Analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT) Introduction The SWOT analytical framework provides a critical scan of areas of strengths within the MHM sector in which actors and sector players can take best advantage of and focus to consolidate gains, weaknesses that require addressing as well as potential opportunities and threats posed within the operating environment. The MHM SWOT analysis has provided the basis of coming up with the MHM policy and strategy and also developing the key strategic areas and priority actions. The SWOT analyses the MHM policy, legal and regulatory situation, enabling environment, coordination, effect of devolution on MHM Programming and forging of partnerships for implementation of the MHM Strategy. The SWOT analysis also looks at the cross-cutting issues such as finance, equity and inclusivity, capacity development and research for evidence creation.

Strengths Weaknesses • Strong coordination mechanism of • Low prioritization of MHM at both the MHM actors National and County levels • Presence of County Officers trained on • A number of policy frameworks MHM with inclusion of MHM are yet to • Developed MHM training materials and be operationalized thus hampering tools delivery of services • Partnerships building on MHM • Inadequate funding for MHM activities • Global trends making MHM gain • Inadequate MHM advocacy traction • Limited involvement of the private • MHM anchored in some government sector in MHM policies • Inadequate guidelines and standards on • Free sanitary pads distribution program MHM in public schools in Kenya • Limited capacity and information • Presence of MHM champion to promote of technologies and innovations for MHM advocacy disposal of menstrual materials and • Political goodwill on MHM products • Inadequate access to affordable menstrual management materials Opportunities • Existing MHM training tools • MHM mentioned in some policies and Threats guidelines developed by the national • Deep rooted cultural inhibitions that and some county governments have promoted stigma and exclusion on • Existing MHM champions that promote menstruation advocacy on MHM issues • Low prioritization of MHM in Kenya • Existing MHM trainers at both the • Lack of clear MHM action plans at both National and County levels the national and County levels • Dearth of data on MHM in Kenya • Exclusion of some key players in the • Leveraging on the international MHM integrated implementation Menstrual Hygiene (MH) Day for MHM • Poor inter-ministerial coordination to advocacy promote the MHM agenda • Existing programmes, projects and • Conflicting Ministry mandates impeding activities to integrate MHM into and slowing down on holistic MHM • Existing Partnerships for MHM support implementation and implementation • Weak MHM monitoring and evaluations • Private sector involvement in MHM systems

11 Political, Economic, Social, Technology, Environmental and Legal (PESTEL) Analysis Introduction During the development of the MHM Strategy, the Political, Economic, Social, Technology and Environmental (PESTEL) tool was used to identify the factors that may affect the implementation of MHM activities in Kenya. The analysis was meant to focus on the environment, in which MHM will be implemented hence, appreciate both factors supporting and hindering the implementation of the MHM Strategy. The table below shows a summary of the results of the PESTEL analysis:

Category Issue Description

Political Constitution of Kenya Chapter Four of the Constitution of Kenya 2010 is an ambitious aspiration that is meant to promote equality, equity, inclusion and non- discrimination based on gender, race, ethnicity etc. The Constitution of Kenya has also adopted and come up with various quota systems that are meant to promote and propagate girls and women issues.

Kenya Vision 2030 Health is one of the components of delivering the Vision’s Social Pillar, given the key role it plays in maintaining the healthy and skilled workforce necessary to drive the economy. The goal aims to develop a population that is healthy, productive and able to fully participate in and contribute to other sectors of the economy.

The Basic Education This addresses the importance of access (Amendment) Act No. to menstrual products for girls in learning 17 of 2017 institutions, and the safe disposal thereof. The document states that the government shall “provide free sufficient and quality sanitary towels to every girl child registered and enrolled in a public basic education institution who has reached puberty and provide a safe and environmentally sound mechanism for disposal of the sanitary towels

12 Category Issue Description

Policies Landscape There are various policies that have been developed in Kenya that will support entrenching of MHM Programme. These include: Kenya Health Policy 2014- 2030; Kenya Environmental Sanitation and Hygiene Policy 2016 – 2030; Kenya School Health Policy (2018). There are other pieces of enabling legislation that promotes various rights to health including sexual and reproductive health in Kenya. These include: The Health Act (2017); Public Health Act Cap 242; (revised 2012) HIV and AIDs Prevention and Control Act (2006); Persons with Disabilities Act (2003); the Sexual Offences Act (2011); the Prohibition Female Genital Mutilation Act no.32 (2012); and National Gender and Equality Commission Act (2012).

Political Goodwill There already exists a pool of champions who will aptly promote issues of MHM in the Country. There are County First Ladies who have been trained on MHM and are implementing an MHM programme in their counties. Two Governors (from Makueni and Kwale) have also been crowned as MHM Champions.

Regional and Globally and regionally, MHM is exponentially International gaining traction. UN Bodies, Development Commitments Partners, Governments, Donors and private sector players are championing issues of MHM.

Economic Goodwill from Kenya is likely to continue enjoying goodwill development partners from all its development partners consequently, this might mean increase in funding for various activities.

Social protection Increase in resources and devolving the resources resources at the Counties present an opportunity for protecting the vulnerable in the society both at the National and County levels.

Budgetary constraints Low prioritization of MHM has translated to low funding of MHM activities thus impeding MHM Programme implementation.

13 Category Issue Description

Social Gender Inequality and Negative gender-based practices continue to be Discrimination prevalent in some communities that limit access to education and other opportunities for young men and women, limiting their participation in development initiatives.

Awareness on MHM There is increased awareness on menstruation due to advocacy efforts in the mainstream media, social media and the internet.

Cultural Beliefs and Deep rooted negative beliefs are an Inhibitions impediment to girls and women management of menstruation with pride and dignity. This has also created a negative perception due to lack of reliable and factual information on menstruation.

Technological Access to Information There is a great opportunity for leveraging on and Communications ICTs in improving uptake of MHM activities. Technologies (ICTs).

Legal Legal provisions Need for harmonization of legal framework for levies and fees for traders operating across counties

Environmental Disposal of used There is a push to have sustainable, accessible, menstrual materials acceptable, safe and affordable varied options and products to dispose of used menstrual materials and products.

14 Chapter Three: Goals, Objectives and Strategies

Vision of the MHM Strategy The vision of the Kenya menstrual hygiene management Strategy is of a transformed country where all the women and girls have access to improved Menstrual Hygiene, where safe hygienic behaviour during menstruation is the norm, and where proper and sound menstrual waste management is widely practiced, leading to improved well-being and full realisation of life.

Mission of the MHM Strategy The mission is to turn the vision of the Kenya Menstrual Hygiene policy into reality in all areas of the Country through a nationwide effort of; Health promotion to improve hygiene, Knowledge and practices, Construction of improved sanitation facilities at household and institutional level and Promotion of safe disposal of used menstrual waste.

Guiding Principles for Implementing the MHM Strategy 1. Menstruation as a human right – The MHM Strategy recognizes that the ability to manage menstruation safely and hygienically, without stigma or taboos, and in dignity is a precondition to meeting the human rights of girls and women. It shall therefore be the responsibility of the state to employ the best and equitable measures to enable the widest possible enjoyment of these rights. 2. Integrated approach – Menstrual Hygiene Management is essentially multi-sectoral. An integrated approach combining MHM education, access to menstrual products, services and facilities, and safe disposal of menstrual waste, ensures improved health, access to education and work, reduced discrimination of women and girls, and increased gender-equality. The successful promotion and implementation of MHM programmes and services will require the involvement of all stakeholders in all stages from the pre- planning stage, through implementation to monitoring and evaluation stages. 3. WASH as a precondition for MHM – Adequate access to Water, Sanitation facilities and an enabling environment to learn about and practice Hygiene are integral to safe and hygienic management of menstruation. 4. Equity – The disadvantaged suffer disproportionately from the barriers of inadequate MHM. Ensuring access to safe, hygienic and dignified MHM for the disadvantaged segments of the population shall be ensured as a means of their health, access to education and work. 5. Social inclusion – Vulnerable sections of the community shall be given priority attention in Menstrual Hygiene Management Promotion. The planning of, investment in, and the promotion of Menstrual Hygiene Services and facilities must therefore address the special needs, interests and priorities of the vulnerable – including persons with disability - to ensure adequate access, usage and maintenance of the facilities and services.

15 6. Education – Comprehensive understanding of menstruation is the best means of addressing myths and taboos, and ensuring the adoption of proper Menstrual Hygiene Practices. Menstrual hygiene information shall therefore be made available in learning institutions, work places, public places and at the household level. 7. Sustainable access – To remove the barriers imposed on women and girls by inadequate MHM, they require sustainable access to menstrual products and services. It shall therefore be the responsibility of the state to create an enabling environment where these products and services can be accessed. 8. Private sector involvement – The private sector shall be encouraged and facilitated for active involvement in the provision of MHM products, facilities and services. The government shall empower and support private sector initiatives with required legal instruments including exemptions and creating the enabling environment such as clear standards and guidelines for the promotion of different technology options by the private sector. 9. Promotion of sustainable, appropriate and affordable menstrual products and facilities – A variety of affordable and appropriate menstrual products and facilities must be available to all users. The advancement and upgrading of technologies and participatory MHM methods through research and development of appropriate and affordable menstrual products and facilities shall be pursued. 10. Safe disposal – The waste resulting from Menstrual Hygiene Management can have significant negative consequences on the environment. Therefore, a set of guidelines will be accompanied by an implementation strategy to ensure that menstrual waste in learning institutions, work places, public places and at the household level is properly managed.

Overall Goal of the MHM Strategy The strategy seeks to contribute to better Menstrual Hygiene Management for women and girls through health research and education and service delivery. It also seeks to raise the level of equality in women and girls capacity for freedom of choice on menstrual management materials enabling them to pursue their goals in life unimpeded. Specific Objectives i. To establish an enabling legal and regulatory environment for MHM at both national and county levels. ii. To ensure that myths, taboos and stigma around menstruation are addressed by providing women, girls, men and boys access to information on menstruation. iii. To ensure women and girls have access to safe and hygienic menstrual products, services and facilities. iv. To ensure a clean and healthy environment for all Kenyans through appropriate technology choices for menstrual waste management and pollution control. v. To establish a functionally effective monitoring and evaluation framework for MHM in Kenya, to ensure maximum accountability in policy implementation at all levels.

16 Strategic Focus Areas The Kenya Menstrual Hygiene Management Strategy 2019 - 2024 provides a medium-term framework for action for both state and non-state actors at national and county levels. The framework sets out strategic focus areas aimed at mainstreaming MHM, strengthening partnerships and coordination, development and maintenance of WASH infrastructure, Strengthening MHM education and awareness, promoting advocacy and resource mobilization, establishing, and strengthening effective monitoring and evaluation systems for MHM. The Menstrual Hygiene Management strategic focus areas are as follows: Strategic focus area 1: Creating an enabling environment for MHM Strategic focus area 2: Breaking the Silence on menstruation Strategic focus area 3: Safe and hygienic management of menstruation Strategic focus area 4: Safe disposal of menstrual waste Strategic focus area 5: Monitoring and Evaluation Systems for Accountability and Learning

Strategic Focus Area 1: Creating an Enabling Environment for MHM Good menstrual hygiene and health practices are integral to empowerment of women and girls through removing barriers and restrictions that impede their full potential and participation. It is incumbent upon the government to create and enhance girls and women ability to manage their menstrual periods with dignity and pride thereby promoting well-being and health. Both the National and County governments should create an enabling environment that will promote implementation of various Menstrual Hygiene Management Programmes as human rights issue. This will entail creation of awareness on menstruation, strengthening institutions and agencies mandated to improve MHM program implementation, integration and mainstreaming MHM, capacity building and promoting investments and funding for MHM activities.

Key Strategic Objective: To establish an enabling legal and regulatory framework for MHM at National and County levels

Key Results: ● Improved coordination of MHM activities at the National and County levels ● MHM integrated into various programs, plans and policies at both the National and County Levels ● MHM Training materials, operational manuals and Policy guidelines developed and disseminated to all the counties in Kenya ● MHM Task Force established at both the National and County levels

17 Key Interventions Recommended/ Proposed Actions Responsible Agency

● Promote the Develop MHM policy guidelines, Ministry of Health and integration/ operational manuals and training County Departments of mainstreaming of materials. Health menstrual health Prepare enabling legislation to provide Ministry of Health and and hygiene for the implementation of the National County Departments of into workplace Menstrual Hygiene Management Health policies, plans and program. programmes Strong leadership and coordination Ministry of Health, County ● Sensitize WASH and health at all levels to build and sustain Departments of Health practitioners on governance for sanitation and hygiene Menstrual Hygiene across MHM related sectors. Management Coordinate inter sectoral initiatives and Ministry of Health, County to promote directives for the implementation of Departments of Health good menstrual MHM nationally and MHM Task Force management practices at all Strengthen partnerships on MHM Ministry of Health, County levels Departments of Health ● Establish a national Enhance Institutional linkages to Ministry of Health, County menstrual sanitary include organizations concerned with Departments of Health commodity supply civic education, as well as the private and MHM Task Force chain system and sector program Establish an MHM Task Force at the Ministry of Health, County national and County levels Departments of Health

Develop a costed annual MHM plan at Ministry of Health, County the National and County level. Departments of Health and MHM Task Force

Develop and implement a national and Ministry of Health, County County MHM resource mobilisation Departments of Health strategy and MHM Task Force

Establish a mechanism to support Ministry of Health, County vulnerable girls and women in special Departments of Health, circumstances such as disaster and Ministry of Planning and emergency situations including Devolution, Ministry internally displaced persons camps to of Interior, MHM Task have access to appropriate menstrual Force Private sector and management materials. partners e.g. Kenya Red Cross

Ensure integration of menstrual health Ministry of Health, County and hygiene issues into various sector Departments of Health, and workplace policies, plans and Ministry of Labour and programmes. MHM Task Force

18 Strategic Focus Area 2: Breaking the Silence on Menstruation Menstruation has been a taboo topic that is shrouded in mystery and silence. The silence has been worsened by existing gender and social norms, societal restrictions, predominant patriarchy, power relations and gender inequality. Menstruation is a natural process and an indicator of health and vitality for girls and women. Awareness on menstruation should be created so that girls and women are able to manage their periods safely and boys and men to support them as they have their menstrual periods. Provision of factual, reliable, pragmatic and age-specific information on menstruation is the only way to break the negative taboos, beliefs and myths and ensure that people are able to talk about menstruation.

Key Strategic Objective: To ensure that menstruation can be discussed without shame and discrimination and women and girls have access to information and services based on their individual contexts and specific needs.

Key Results: ● Improved knowledge on menstruation and MHM in Kenya ● MHM integrated into reproductive health and hygiene, School Health and Adolescent Policy ● MHM included in school curriculum ● A sustainable and effective MHM media and advocacy campaign in place ● MHM Communication and Media Strategy and MHM IEC materials developed Key Interventions Recommended/ Proposed Actions Responsible Agency

● Inclusion of MHM Advocate for the inclusion and Ministry of Health, into reproductive integration of information related to County Departments health and MHM into general, reproductive health of Health and National hygiene education and hygiene education materials, and Counties’ MHM Task training materials, school health and adolescent policy Forces education, school health policy, adolescent policy, community health strategy ● Develop MHM communication and media strategy, media advocacy and awareness campaign and MHM IEC materials ● Include MHM in the school curriculum ● Identify and work with MHM champions to create awareness on menstruation and MHM

19 Key Interventions Recommended/ Proposed Actions Responsible Agency Advocate for the revision of curriculum Ministry of Health, materials used in Life Skills Education County Departments in schools to include specific topics on of Health and National MHM. and Counties’ MHM Task Forces

Develop an MHM communication Ministry of Health, strategy that will take into County Departments consideration the persons with of Health and National disabilities and various cultural and and Counties’ MHM Task geographical settings. Forces

Develop Information, Education Ministry of Health, and Communication (IEC) materials County Departments on MHM such as posters, fliers and of Health and National leaflets. and Counties’ MHM Task Forces

Recognize and work with MHM Ministry of Health, champions in the communities to County Departments provide awareness during community of Health and National dialogue days and International and Counties’ MHM Task Menstrual Hygiene day. Forces

Integrate MHM in other global Ministry of Health, advocacy days such as Global Hand County Departments Washing Day, World Toilet Day, World of Health and National Water Day, International Day for Girl, and Counties’ MHM Task Day of the African Child, World Aids Forces Day, International Women’s Day etc

Carry out social mobilization and Ministry of Health, sensitization on MHM in all settings. County Departments of Health and National and Counties’ MHM Task Forces

Promote male involvement in MHM Ministry of Health, activities. County Departments of Health and National and Counties’ MHM Task Forces

Promote MHM as a rights-based Ministry of Health, intervention for girls and women in County Departments hard to reach areas and for people with of Health and National disabilities. and Counties’ MHM Task Forces

20 Key Interventions Recommended/ Proposed Actions Responsible Agency Undertake collaborative initiatives with Ministry of Health, the private sector for promoting MHM County Departments hygienic behaviour of Health and National and Counties’ MHM Task Forces

Align and mainstream MHM education Ministry of Health, within the school curriculum County Departments of Health, Kenya Institute of Curriculum Development and National and Counties’ MHM Task Forces

Mainstream MHM awareness with the Ministry of Health, County community Health strategy and school Departments of Health, hygiene education. Community Health Strategy at National and County levels and National and Counties’ MHM Task Forces

The Ministry of Health in collaboration Ministry of Health, County with the media shall establish and Departments of Health implement a media awareness and National, Counties’ programme and campaign for creating MHM Task Forces, media awareness on menstruation and good personalities and media menstrual management practices. stations

Develop an effective MHM advocacy Ministry of Health, initiative that targets influential County Departments persons within the society and develop of Health and National MHM champions to advocate for good and Counties’ MHM Task menstrual management practices. Forces

Strategic Focus Area 3: Safe and Hygienic Management of MHM Safe management of menstruation entails access to safe menstrual management materials that can absorb and collect blood and access to facilities that provide and ensure privacy that girls and women can use to change menstrual materials and soap and water to wash themselves during their menstrual periods. Access and use of menstrual materials to manage periods and sanitation facilities to wash themselves will promote dignity of women and girls as they have their menstrual periods. Availing information on all the available menstrual management materials (disposable pads, reusable menstrual materials and re-usable (menstrual cups) will ensure that girls and women make informed choices on the options that they would want to use.

21 Key Strategic Objective: To ensure that all women and girls have access to services and products required to manage menstruation

Key Results: ● Access to safe and affordable menstrual management materials for women and girls increased by at least 30% by 2020 ● 100% of public schools with girls regularly supplied with sanitary towels/pads ● Improved school attendance rates and performance levels for girls ● Fully functioning national menstrual sanitary commodities supply chain system established

Key Interventions Recommended/ Proposed Actions Responsible Agency

● Promote access to Develop and enforce systems for Ministry of Health, safe and affordable construction and maintenance of County Departments menstrual standardized WASH facilities and of Health and National management waste disposal facilities in schools and and Counties’ MHM Task materials households Forces

● Provide guidelines Develop and review standards for Ministry of Health on construction menstrual management products and and Kenya Bureau of of MHM friendly materials Standards (KEBS) facilities Promote innovative and affordable Ministry of Health, ● Promote Private sector involvement interventions for MHM with vulnerable County Departments in provision of safe and marginalized females as specific of Health and National and affordable targets for these interventions. and Counties’ MHM Task menstrual Forces materials, products Support and strengthen the Ministry of Health, and WASH facilities participation of local communities County Departments ● Establish a national for improving Menstrual Hygiene of Health and National menstrual sanitary Management through water, and Counties’ MHM Task commodity supply sanitation, hygiene and environmental Forces chain system and management program Promote MHM as a rights-based Ministry of Health, intervention for girls and women in County Departments hard to reach areas and for people with of Health and National disabilities. and Counties’ MHM Task Forces

Undertake interventions on MHM Ministry of Health, within the context of, and in line with County Departments the principles of basic health care in of Health and National Kenya and Counties’ MHM Task Forces

22 Key Interventions Recommended/ Proposed Actions Responsible Agency

Enforce relevant laws to maintain Ministry of Health, standards of WASH/MHM facilities County Departments of Health and National and Counties’ MHM Task Forces

Ensure that women and girls have Ministry of Health, access to a range of menstrual hygiene County Departments management products that are of Health and National acceptable, safe and affordable and Counties’ MHM Task Forces

Facilitate and encourage research, Ministry of Health, innovation and standards to ensure the County Departments development of appropriate menstrual of Health and National hygiene products. and Counties’ MHM Task Forces

Create an enabling environment Ministry of Health, for investments in the sector to County Departments produce low cost menstrual hygiene of Health and National products. and Counties’ MHM Task Forces

Promote provision of WASH facilities Ministry of Health, in all households, learning institutions, County Departments public places, health care facilities, of Health and National workplaces and correctional facilities and Counties’ MHM Task Forces

Strategic Focus Area 4: Safe Disposal of Menstrual Waste Women and girls need to know and use the various safe disposal methods for disposing their menstrual waste. Cultural inhibitions and restrictions and lack of information on available and safe disposal methods have exacerbated the menstrual waste problem. To realise the use of safe and hygienic options for menstrual management, safe management of menstrual waste must be part of programmatic and policy dialogues. The voices of girls and women, as well as of waste collectors need to be incorporated to ensure that appropriate solutions are implemented. Menstrual waste management need to be part and parcel of the greater solid waste management. Innovations and various technologies should be harnessed and be made context specific.

23 Key Strategic Objective: Promote sustainable MHM waste management practices and ensure a clean healthy environment for all Kenyans

Key Results: ● Increased private sector participation in Menstrual waste disposal ● Standards for menstrual waste management have been developed ● Various menstrual waste innovations and approaches have been documented and regularly updated

Key Interventions Recommended/ Proposed Actions Responsible Agency

● Promote Promote research, standard Ministry of Health, public-private development and appropriate County Departments participation in incubation of programmes for of Health and National menstrual waste development of effective menstrual and Counties’ MHM Task management waste management systems for Forces ● Document various storage, collection, transportation, menstrual waste treatment and disposal innovations and Promote Public Private partnerships Ministry of Health, approaches (PPP) for increased investments in County Departments ● Develop standards menstrual waste management of Health and National for menstrual and Counties’ MHM Task waste management Forces including menstrual waste minimisation Recommend all public spaces to have Ministry of Health, MHM waste receptacles County Departments ● Encourage and of Health and National promote research and Counties’ MHM Task into menstrual Forces waste management ● Review the Develop standards for menstrual Ministry of Health, Healthcare Waste waste management process: storage, County Departments Management collection, transportation, treatment of Health and National Policy, Strategy and disposal and Counties’ MHM Task and Guidelines to Forces include Menstrual Review of healthcare waste Ministry of Health, waste management management policy, strategy, County Departments guidelines and standard operating of Health and National procedures to in-cooperate Menstrual and Counties’ MHM Task Hygiene Management wastes and Forces procedures connected thereto.

Support research and studies in Ministry of Health, volumes and types of waste from County Departments predominant sectors and segments of Health and National of the economy (especially sources of and Counties’ MHM Task non-biodegradable-organic-fractions, Forces special and hazardous wastes).

24 Key Interventions Recommended/ Proposed Actions Responsible Agency

Document various menstrual waste Ministry of Health, management innovations. County Departments of Health and National and Counties’ MHM Task Forces

Strategic Focus Area 5: Monitoring and Evaluation Systems for Accountability and Learning All strategic focus areas require continuous monitoring. Evaluating outcomes, trends and impacts of interventions is critical in the assessment of collective efforts by MHM stakeholders. Continuous measurement of progress and impact of the implementation of MHM strategies, is essential to achieving the planned interventions. In addition, M&E systems are vital for effective and sustainable program implementation.

Key Strategic Objective: To ensure effective monitoring and evaluation of Menstrual hygiene Management interventions

Key Results: ● MHM indicators developed ● MHM activities routinely measured and reported ● Fully operational and vibrant National and County MHM data and information sharing platforms ● MHM indicators included in the DHIS reporting system Key Interventions Recommended/ Proposed Actions Responsible Agency

● Develop MHM Institute effective M&E systems at Ministry of Health, specific indicators all levels to ensure coordinated and County Departments ● Promote routine sustained improvement of MHM. of Health and National reporting of MHM and Counties’ MHM Task activities at the Forces National and Develop MHM specific indicators Ministry of Health, County levels -and integrate them into all levels of County Departments ● Include MHM reporting systems of Health and National indicators in the and Counties’ MHM Task DHIS reporting Forces system Strengthen staff capacity at County, Ministry of Health, ● Encourage and Inter-County and National level to County Departments promote MHM use the MHM M&E tools in collection, of Health and National research within the collation, reporting and utilization of and Counties’ MHM Task country MHM data to inform policy changes. Forces ● Mobilise funding for MHM M&E and research

25 Key Interventions Recommended/ Proposed Actions Responsible Agency Develop and promote adherence to Ministry of Health, the MHM protocols by all actors in the County Departments MHM of Health and National and Counties’ MHM Task Forces

Develop MHM specific and sensitive Ministry of Health, indicators -and integrate them into all County Departments levels of reporting systems of Health and National and Counties’ MHM Task Forces

Establish mechanisms for the collection Ministry of Health, and reporting of disaggregated data County Departments for decision making in MHM. of Health and National and Counties’ MHM Task Forces

Encourage key stakeholders to conduct Ministry of Health, operational researches to establish County Departments effective and sustainable sanitation of Health and National systems in the country. and Counties’ MHM Task Forces

Establish effective Monitoring and Ministry of Health, evaluation (M & E) systems to monitor County Departments inputs, processes and outputs. of Health and National and Counties’ MHM Task Forces

Develop standardize MHM M&E tools Ministry of Health, and specific indicators and integrate County Departments them into DHIS at all levels. of Health and National and Counties’ MHM Task Forces

Research into the adoption of Ministry of Health, environmentally friendly menstrual County Departments hygiene materials and products of Health and National followed by the accreditation of and Counties’ MHM Task production facilities in partnership with Forces the private sector.

Establish Intra- County, Inter-County Ministry of Health, and National MHM data review and County Departments information sharing platforms of Health and National and Counties’ MHM Task Forces

26 Chapter Four: MHM Strategy Implementation Arrangement

Introduction Kenya has adopted a three-pronged approach to Menstrual Hygiene Management (MHM). This entails: i. Breaking the Silence on menstruation ii. Safe and hygienic management of menstruation iii. Safe disposal of used menstrual materials/Safe re-use of menstrual materials i. Breaking the Silence on menstruation Menstruation is shrouded in mystery, secrecy and silence. It is a taboo topic that should not be discussed openly and rather in secrecy. Due to this, communities have come up with various beliefs, myths and taboos surrounding menstruation. This has largely been caused by lack of reliable, pragmatic and factual information on menstruation. When having their first period (menarche), girls have gone through embarrassment, shame, disgust and confusion simply because they never knew what was happening to their bodies. There is need to provide girls with factual information on menstruation and management of menstruation before they have their menarche. Provision of reliable information will also help to dispel and break the various negative myths and taboos around menstruation hence, girls and women will in turn go through their menstrual periods with dignity and pride. ii. Safe and hygienic management of menstruation Girls and women need to have information on the various options available to manage their menstrual flow. It is important to provide information on the various menstrual products and materials (disposable, reusable sanitary pads) that are used to manage menstruation for girls to make informed choice on the option that they would prefer. Girls and women also need facilities that will provide privacy for changing sanitary pads and washrooms with water and sanitary pads disposable bins. Girls’ and women’s life should not be impeded simply because they are having their menstrual periods. iii. Safe disposal of used menstrual materials/Safe re-use of menstrual materials Menstrual waste, just like other wastes, should be disposed of in a safe manner. The disposal method should be environmentally friendly, acceptable, accessible, available and affordable to the users. Lack of information on the recommended and good disposable methods has led to crude dumping and indiscriminate burning of used sanitary pads and other menstrual materials. There are also reusable menstrual materials that girls and women need to know how to re-use them safely. Their safe use will entail how to wash them and dry them and store. In order to effectively implement the aforementioned strategic action points, the following set of actions are required at leadership and operational levels.

27 Leadership Alignment to Oversee Implementation of the MHM Policy MHM implementation will demand a multi-sectoral approach that will include varied stakeholders under the leadership of the Ministry of Health. The following will have to be done to appropriately develop consensus on MHM implementation: a) Orientation on the guidelines: Convene a session with the executive leaders at the Ministry of Health to create buy-in of the leadership for achieving the objectives and action points. b) Orientation of the Heads of Department (HODs) on the content of this document and its application in converging health sector M&E investments. c) At the National level, convene an orientation meeting bringing together National MOH officials, HODs, heads of divisions and units, related ministries, Semi-Autonomous Government Agencies (SAGAs), development partners and top county health officials. d) County level buy-in will be continuous process facilitated through the Hygiene Promotion Technical Working Group (TWG) of the National Environmental Sanitation and Hygiene Inter-Agency Coordinating Committee, which will assume the responsibility for mobilizing the leadership in each county to support the MHM reform agenda. Dissemination of the MHM Strategy a) Develop dissemination materials such as annotated diagrams, PowerPoint presentations and infographics that enable simplified communication with stakeholders at different levels. b) MHM Documents and guides and other hyperlinked documents will be made available to all stakeholders. c) Dissemination will be done through pre-arranged forums and meetings to raise awareness of the strategy to all stakeholders. d) At the County level, dissemination meetings will be held in each County and will bring together County health officials, sub county health management teams and implementing partners. e) At the sub County level, there will be meetings for the sub County health officials, Community Health Workers (CHWs), Village Health committees and implementing partners. CHWs will be expected to disseminate the strategy through the routine village dialogue platforms and adopt them as a best practice. f) A popular version of the MHM Policy and Strategy will be developed and be added as an accompanying document to both the documents.

Implement Formative Technical Interventions on MHM Formative activities to roll out this strategy will include: • Conducting sector-wide MHM capacity assessment to develop capacity building programs that address the most critical challenges associated with MHM. This should be accompanied by a change management action plan, which is informed by the findings of the MHM capacity assessment. • Provide support to Counties, Environmental health programs and other organizations to develop and periodically review MHM and sanitation plans. • Support the establishment of MHM task forces at the national and county level.

28 In order to ensure sustainability for MHM implementation in the health sector, there is a need to invest in strong and vibrant technical coordination platforms that can sustain the agenda for change at all times and at all levels. Using the platform of the Inter Agency Coordinating Committee and its TWGs for engaging leadership at MOH and at the County level, advocacy should commence through a stakeholders’ roundtable meeting on MHM, which will also be used to develop an annual capacity improvement plan with full resource commitment by different partners and stakeholders. At the National level, the MHM TWG should convene development partners around the MHM roadmap for MHM strengthening within the framework of the collaboration.

Implementation of The Basic Education Ammendment Act The Act mandates the Cabinet Secretary in charge of basic education and training to provide free, sufficient and quality sanitary towels to every girl registered and enrolled in public basic education institution who has reached puberty and, provide a safe and an environmentally sound mechanism for disposal of the sanitary towels. The Ministry of Education shall be responsible for the distribution of menstrual management products to girls who have attained puberty age in all primary schools. The Ministry of Education shall develop distribution guidelines to ensure that the process is seamless, above board and the menstrual materials distributed are safe and of good quality. The Ministry of Education shall ensure that all schools receiving the menstrual management materials have standardised self-closing bins that the girls will use to dispose the menstrual waste. Ministry of Education shall construct incinerators in some schools within the Country and neighbouring schools can transport their menstrual waste to the incinerators. Schools that are near health facilities that have incinerators shall be expected to transport the menstrual bins to the health facilities for incineration. The Ministry of Education through the allocated budget provision shall construct airtight pits that will be used to hold the disposed menstrual waste. The Ministry of Health shall ensure the safety of the menstrual management materials, the bins, pits and incinerators and safety of the persons involved in the disposal, containment, transportation and incineration of the waste. The National Environment Management Authority (NEMA) shall ensure compliance of the incinerators and pits to environmentally sound structures and regulations. The Ministry of Education shall be expected to provide data and quarterly reports to the Cabinet on the implementation of the Basic Education Amendment Act.

Strengthen Coordination for MHM at the National and County Levels In order to sustain the momentum for reforms, it is important to create a sense of urgency among existing platforms for MHM advocacy and oversight. The Technical Working Groups under the Ministry of Health, will be critical platforms for mobilizing support for sector-wide MHM priorities. When fully functional, they will provide mechanisms for mutual accountability among stakeholders implementing different components of the MHM system. The Ministry of Health under the aegis of the Hygiene Promotion TWG will spearhead the formation of the MHM task force at both the National and County levels. The MHM task force shall draw membership from various Departments and Divisions within the MoH, interrelated ministries,

29 UN agencies, Development partners, NGOs, the private Sector and other related government bodies. The MHM task force shall comprise the following:

1. Ministry of Health a) Department of Environmental Health – Water Safety and Sanitation Unit (Convener) b) Division of Family Health–Neonatal, child and adolescent health unit, Reproductive and maternal health unit

2. Related Ministries a) Ministry of Water, Sanitation and Irrigation b) Ministry of Environment and Forestry c) Ministry of Devolution and Planning d) Ministry of Education e) Ministry of Public Service, Youth and Gender Affairs (Form the State Department of Gender overseeing the free Sanitary pad distribution programme in schools) f) Office of the Attorney General g) Ministry of Labour and Social Protection h) National Treasury

3. Semi-autonomous Government Agencies a) National Environment Management Authority (NEMA) b) Kenya Bureau of Standards c) Kenya Industrial Research Development Institute (KIRDI)

4. UN Agencies 5. Development Partners 6. NGOs 7. Private Sector 8. Representative from academia and/or research institution

The task force shall be expected to meet at least once a quarter and will oversee the implementation of the MHM programme under the guidance of the Hygiene Promotion TWG. The MHM task force shall perform the following functions: i. Coordinate MHM stakeholders Nationally and in the Counties ii. Develop and review national policies, strategies, regulations and guidelines relevant to the MHM and collaboration with partners iii. Develop National MHM action plan cascaded to the Counties

30 iv. Oversee the implementation of MHM activities Nationally and in the Counties v. Provide effective strategic multi-sectoral leadership on MHM vi. Coordinate MHM advocacy work and information and knowledge management vii. Provide MHM technical support and capacity building to Counties viii. Explore new and innovative approaches to MHM interventions and achievement of the MHM Strategy results ix. Coordinate with partners to develop MHM research agenda and identify, conceptualize and articulate areas for research and knowledge building x. Ensure effective communication and co-operation between different agencies involved in environmental sanitation, within the context of a coherent national ESH strategy xi. Coordinate, monitor and evaluate MHM performance and report on the activities xii. Develop guidelines for the free sanitary pad distribution programme

Design and Roll Out a Comprehensive Capacity Development Plan Targeting Actors at all Levels. Once the strategy is endorsed and adopted by the Government, consensus will be needed on the costed MHM Action plan. This plan will become the basis for advocacy and engagement with the government at the national and County levels to increase allocations and direct investments to Menstrual Hygiene Management capacity strengthening.

MHM Integration into Various Sectors Programmes and Activities For successful implementation of MHM, apart from having a National MHM Programme, emphasis need to be laid on integration of MHM into already existing programmes and activities in various sectors. MHM permeates across various aspects of life and integration will strengthen MHM uptake and efficiency in programming. It will also promote access to information at scale and eventually for various actors to view MHM as a right. For effective implementation of the MHM Strategy, the following programmes and activities can be considered:

Sector Interventions Rationale for Integration

Maternal and Child Beyond Zero Programme run by the First Lady of Kenya and the Health Programmes Counties that seeks to prevent maternal and child deaths provides an avenue to disseminate information about menstruation, menstrual hygiene and health to the mothers.

31 Sector Interventions Rationale for Integration

Family Planning Some women have viewed the menstrual changes associated with Programmes contraceptive use, especially increased or irregular bleeding, as a negative or undesirable side effect. However, recent evidence suggests that decreased bleeding, and amenorrhea in particular, is acceptable to women and is even considered an important side benefit. Surveys have shown that teens and young women are especially interested in limiting or controlling the timing of menstruation through the use of hormonal contraceptives. For young women in developing countries, where access to menstrual hygiene supplies and safe places to manage their menses are sometimes limited, the advantage of contraceptive-induced menstrual control could be especially important. Youth-focused family planning initiatives are critical and could create a bridge between the MHM and family planning fields. Such linkages could focus on helping young women who are ready to use contraception learn how different family planning methods may affect their menstruation.7

Sexual and MHM has become a health concern due to the associations between Reproductive Health poor MHM and adverse health effects. Among the negative health (and Rights) effects are Reproductive Tract Infections (RTIs) which are common and predominantly found in developing countries.8 Poor MHM is mainly associated with the RTIs called ‘endogenous infections’, including bacterial vaginal infections (causing vaginal odor, discharge, and pain) and Vulva Vaginal Candidiasis (or vaginal thrush, an infection of the vagina’s mucous membrane, causing itching, abnormal vaginal discharge and making sexual intercourse and urination painful).9

Female Genital A study conducted by UN Women and WSSCC in Senegal to Mutilation (FGM) determine the link between MHM and FGM found out that women who have gone through FGM have less appropriate knowledge in MHM than non-mutilated women. Furthermore, they use disposable or single-use sanitary protection more than non-mutilated women do and they are at a higher risk than non-mutilated women of health problems during their periods.10

7 Callahan, R., Rademacer, K. & Wilson, L. (2015) Common Cause: Linking Menstrual Hygiene Management and Long-acting Contraception to Improve Youth Reproductive Health. https://www.twigh.org/twigh-blog-ar- chives/2015/5/28/common-cause-linking-menstrual-hygiene-management-and-long-acting-contraception-to-im- prove-youth-reproductive-health 8 Rheinländer, T. and Wachira, M. (2015) Menstrual Hygiene: An ancient - but ignored Global Health problem of all women. http://www.globalhealthminders.dk/wp-content/uploads/2015/03/GHM-MenstrualHygiene-Brief.pdf 9 Sumpter, C., Torondel, B. (2013). A systematic review of the Health and Social Effects of Menstrual Hygiene Man- agement, PLOS ONE, April 2013: 8:4. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0062004 10 WSSCC & UN Women (2018) Menstrual Hygiene Management and Female Genital Mutilation: Case Studies in Sene- gal https://www.wsscc.org/wp-content/uploads/2018/01/20171227_Policy-GHM-Senegal-EN-WEB-1.pdf

32 Sector Interventions Rationale for Integration

Gender Based Girls and women are highly vulnerable to gender-based violence, Violence including harassment, physical assault, and/or rape; this vulnerability is exacerbated by limited access to WASH facilities. Some girls’ and women’s have reported experiences of rape when using toilets, taking a bath, or collecting water, as well as when they leave their communities at night to defecate in private—a common socio- cultural norm. It follows that girls and women are at increased risk of gender-based violence while menstruating, due to the need for increased access to WASH facilities, desire to hide evidence of menstruation, and lack of sanitation in homes. Risk of gender- based violence during menstruation may be particularly high for adolescent girls, who experience sexually threatening behavior from their male classmates and teachers, as well as from family members and family friends. Moreover, girls and women in humanitarian relief environments may also be at particular risk of violence. The limited infrastructure means women and girls may have to travel far from home at odd hours to privately change and wash their menstrual materials.11

HIV/AIDS Campaigns With the increased availability of HIV treatment and adherence support, more women and girls living with HIV are now healthy and returning to having periods. HIV has a limited lifespan outside the body, but handling fresh blood does carry a risk, if someone has open cuts on their hands. Care should be taken when disposing of freshly used pads, or washing an AIDS patient who is having a period.

Adolescent Health Menstrual Hygiene Management (MHM) is a problem for adolescent Interventions and girls in low- and middle-income countries (LMICs), particularly when Programmes attending school. Poor water, sanitation and hygiene (WASH) facilities in schools, inadequate puberty education and lack of hygienic MHM items (absorbents) cause girls to experience menstruation as shameful and uncomfortable.12

11 PATH (2016) Girls’ and women’s right to menstrual health: Evidence and opportunities https://path.azureedge.net/ media/documents/RH_outlook_mh_022016.pdf 12 van Eijk AM, Sivakami M, Thakkar MB, et al Menstrual hygiene management among adolescent girls in India: a sys- tematic review and meta-analysis Open 2016;6:e010290. doi: 10.1136/bmjopen-2015-010290

33 Sector Interventions Rationale for Integration

Psychosocial Well- Research has linked poor MHM to negative consequences for women’s being and Mental dignity, health, education, work, and psychosocial wellbeing.13 Health Availability of peer and other Social support mechanisms, inhibitions and restrictions during menstrual periods, promotion of self-esteem and confidence through good menstrual management practices are factors that will have a direct effect on a girl’s psychosocial well being and limit or increase her productivity in life.

Education Menstrual Hygiene Management (MHM) is a major health issue Programmes affecting women and girls of reproductive age worldwide. The transition into reproductive age for some girls is often met with fear and anxiety due to a lack of knowledge about menstruation and a lack of resources about the changes that are occurring in their bodies. School-aged girls, especially in marginalised communities, face the largest barriers to MHM, as many schools do not have the necessary facilities, supplies, knowledge, and understanding to appropriately support girls during menstruation. This negatively impacts their education and ability to stay in school. Furthermore, schools often have inadequate water and sanitation available, making menstrual hygiene almost impossible to maintain, causing stress and embarrassment for female students. Communities often hold local cultural beliefs or taboos related to menstruation that can threaten a girl’s physical and/or emotional well-being.14

Gender Awareness Promotion of gender parity and equality has gained momentum Campaigns and traction. MHM education should be included in breakdown of negative gender norms that promote discrimination and inequality. Menstruation is shrouded in mystery, taboos, stigma and silence. This is largely due to power relations, gender stereotyping and gender roles and expectations. MHM can be used as an entry point to discuss some of these key gender concepts.

Campaigns to end Child marriages are normally initiated with the onset of menstruation. child marriages Girls who begin having their periods are deemed as ‘women’ and hence ready for marriage. Menstruation is a landmark change in girls and should be viewed as natural biological process. Girl and proponent of early child marriages should be included in MHM discourse.

13 Hennegan, J. (2016) Women and water: Menstrual hygiene management and current evidence for interventions. Global Water Forum. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0146985&type=print- able 14 World Vision International (2016). Menstrual Hygiene Management. Available online: https://www.wvcentral.org/ community/wash/Pages/Menstrual-Hygiene-Management.aspx

34 MHM STRATEGY IMPLEMENTATION FRAMEWORK

Strategic Focus Area 1: Creating and enabling Environment for MHM Key Strategic Objective: To establish an enabling legal and regulatory framework for MHM at National and County levels Expected Outcomes: ● Improved coordination of MH activities at the National and County levels ● MHM integrated into various programs, plans and policies at both the national and County Levels ● MHM Training materials, operational manuals and Policy guidelines developed and disseminated to all the counties in Kenya ● MHM Task Force established at both the National and County levels Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Promote Develop MHM Presence Ministry X 6M integration/ policy guideline of Policy of Health, mainstreaming Guidelines County of menstrual Departments health and of Health and hygiene into MHM Task workplace Force policies, plans and programmes Establish MHM Develop Presence of Ministry X 4M Task forces MHM training developed of Health, at both the materials training County National and materials Departments Counties’ level of Health and to coordinate MHM Task MHM activities Force Develop Prepare Presence of Ministry X 5M MHM Policy enabling MHM legislation of Health, Guidelines, legislation to passed by County MHM provide for the relevant body Departments legislation and implementation of Health and MHM Training of the National MHM Task Materials Menstrual Force Hygiene Management program. Establish an Functional Ministry X 5M MHM Task MHM Taskforce of Health Force at the at the National and County national and level Departments County levels of Health No. of counties Ministry X 4M with actively of Health, running MHM County Task force Departments of Health and MHM Task Force

35 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Develop a Presence of Ministry X 6M costed annual National MHM of Health, MHM plan at Annual plan County the national and Departments County level. of Health and MHM Task Force No. of Counties Ministry X 2M that have of Health, domesticated County the National Departments MHM annual of Health and Plan MHM Task Force Develop and Presence of Ministry X implement a National MHM of Health, national and Resource County County MHM Mobilization Departments resource Strategy of Health and mobilisation MHM Task strategy Force No.of Counties Ministry X 6M that have of Health, developed County and are Departments implementing of Health and County MHM MHM Task Resource Force Mobilization Strategy Enhance No. of Ministry X 6M Institutional organizations of Health, linkages and private County to include sector players Departments organizations collaborating of Health and concerned with with MoH to MHM Task civic education, undertake MHM Force as well as the activities private sector

36 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Establish a No. of Ministry X 10M mechanism vulnerable girls of Health, to support and women County vulnerable girls reporting Departments and women increased of Health and in special access to MHM Task circumstances menstrual Force such as disaster management and emergency materials as situations a result of including established internally MHM support displaced mechanism persons camps to have access to appropriate sanitary towels Ensure Number and list Ministry X 10M integration of programmes of Health, of menstrual that have County health and integrated Departments hygiene issues MHM of Health and into various MHM Task sector and Force workplace policies, plans and programmes

37 Strategic Focus Area 2: Breaking the Silence on Menstruation Key Strategic Objective: To ensure that menstruation can be discussed without shame and discrimination and women and girls have access to information and services based on their individual contexts and specific needs. Expected Outcomes: ● Improved knowledge on menstruation and MHM in Kenya ● MHM integrated into reproductive health and hygiene, School Health, Adolescent Policy and Communication Strategy ● MHM included in school curriculum ● A running, sustainable and effective MHM media and advocacy campaign ● MHM Communication and Media Strategy and MHM IEC materials developed Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicator Inclusion of Advocate for Number and list Ministry X 10M MHM into the inclusion of Policies that of Health, reproductive and integration have a mention County health and of information of MHM Departments hygiene related to MHM of Health and education into general, MHM Task training reproductive Force materials, health and education, hygiene school education health policy, materials, adolescent school health policy, and adolescent community policy health strategy Develop MHM Develop Presence Ministry X 10M communication an MHM of MHM of Health, and media communication Communication County strategy, media strategy that Strategy Departments advocacy and will take into with specific of Health and awareness consideration mention of MHM Task campaign the persons the various Force and MHM IEC with disabilities vulnerabilities materials and various cultural and geographical settings. Develop a Fully running X media advocacy and sustainable and awareness media campaign campaign No. of people 3M reporting reached with MHM messages through the media

38 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Include MHM Develop No. of MHM Ministry X in the school Information, IEC materials of Health, curriculum Education and developed County Communication Departments (IEC) materials of Health and on MHM such MHM Task as posters, fliers Force and leaflets. No. of people 5M (segregated by gender, disability, vulnerability) reached with MHM IEC materials Identify Recognize and No. of MHM Ministry X X X X and work work with MHM Champions of Health, with MHM champions actively County champions in the engaging in Departments to create communities MHM activities of Health and awareness on to provide MHM Task menstruation awareness Force and MHM during community dialogue days and International Menstrual Hygiene day. Align and MHM included Ministry X mainstream as apart of of Health, MHM education the school County within the curriculum Departments school of Health and curriculum MHM Task Force Integrate MHM MHM Ministry X X X X 10M in other global integrated into of Health, advocacy days other global County such as Global advocacy days Departments Handwashing of Health and Day, World MHM Task Toilet Day, Force World Water Day, International Day for Girl, Day of the African Child, World Aids Day, International Women’s Day etc

39 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Carry out social No. of social Ministry X X mobilization mobilization of Health, and and County sensitization sensitization Departments on MHM in all meetings of Health and settings. undertaken MHM Task Force No.of people Ministry reached of Health, in social County mobilization Departments and of Health and sensitization MHM Task meetings Force Promote male No.of males Ministry X X X X involvement in reached with of Health, MHM activities. MHM messages County Departments of Health and MHM Task Force No.of males Ministry 5M reporting active of Health, involvement in County MHM activities Departments of Health and MHM Task Force Undertake Number and Ministry X X X X 10M collaborative list of private of Health, initiatives with sector players County the private undertaking Departments sector for holistic MHM of Health and promoting activities MHM Task MHM hygienic Force behaviour Mainstream MHM Ministry X 5M MHM mainstreamed of Health, awareness with into the County the community Community Departments Health strategy Health Strategy of Health and and school MHM Task hygiene Force education.

40 Strategic Focus Area 3: Safe and hygienic management of menstruation Key Strategic Objective: To ensure that all women and girls have access to services and products required to manage menstruation Expected Outcome: ● Access to safe and affordable menstrual management materials for women and girls increased by at least 30% by 2020 ● 100% of public schools with girls regularly supplied with menstrual management materials ● Improved school attendance rates and performance levels for girls ● Fully functioning national menstrual sanitary commodities supply chain system established Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicator Promote Develop and Presence of Ministry X 5M access to safe enforce systems standards for of Health and affordable for construction WASH facilities and County menstrual and Departments management maintenance of Health materials of standardized WASH facilities and waste disposal facilities Provide Develop Presence of Ministry X 5M guidelines on and review standards for of Health construction of standards for menstrual and County MHM friendly menstrual management Departments facilities management materials of Health products and materials Promote Promote Documented Ministry X X X X X 5M Private sector innovative and MHM of Health involvement affordable innovations for and County in provision interventions vulnerable and Departments of safe and for MHM with marginalised of Health affordable vulnerable and women and menstrual marginalized girls materials, females as products and specific targets WASH facilities for these interventions. Establish Support and No. local Ministry X X X X X a national strengthen the communities of Health menstrual participation members and County sanitary of local participating Departments commodity communities on initiatives of Health supply chain for improving to strengthen system and Menstrual MHM program Hygiene Management through water, sanitation, hygiene and environmental management

41 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Ensure that Proportion of Ministry X X X X X 10M women and women and of Health girls have access girls accessing and County to a range of acceptable, safe Departments menstrual and affordable of Health hygiene menstrual management management products that materials are acceptable, safe and affordable

42 Strategic Focus Area 4: Safe Disposal of menstrual waste Key Strategic Objective: Promote sustainable MHM waste management practices and ensure a clean healthy environment for all Kenyans Expected Outcomes: ● Increased private sector participation in Menstrual waste disposal ● Standards for menstrual waste management have been developed ● Various menstrual waste innovations and approaches have been documented and regularly updated Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicator Promote Promote No. of Ministry X 10M public-private research, researches of Health, participation standard conducted Ministry of in menstrual development on menstrual Environment, waste and appropriate waste disposal NEMA and management incubation of County programmes for Departments development of Health of effective menstrual waste management systems for storage, collection, transportation, treatment and disposal. Document Promote Percentage of Ministry X X X X X 5M various Public Private MHM funds/ of Health, menstrual partnerships investment Ministry of waste (PPP) for realised Environment, innovations increased through PPPs NEMA and and investments County approaches in menstrual Departments waste of Health management Develop Recommend No.of Ministry X X X X X 10M standards for all public receptacles of Health, menstrual spaces to have constructed Ministry of waste MHM waste for disposal Environment, management receptacles of Menstrual NEMA and including waste in public County menstrual spaces Departments waste of Health minimisation

43 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Develop Available Ministry X 5M standards for standards for of Health, menstrual menstrual Ministry of waste waste Environment, management management NEMA and process: County storage, Departments collection, of Health transportation, treatment and disposal Encourage Review of Healthcare Ministry X 5M and promote healthcare waste of Health, research into waste management Ministry of menstrual management policy, strategy Environment, waste policy, strategy, and standard NEMA and management guidelines operating County and standard procedures Departments operating reviewed of Health procedures to to include in-cooperate menstrual Menstrual waste Hygiene management Management wastes and procedures connected thereto. Review the Support No. of studies Ministry X 6M Healthcare research conducted on of Health, Waste and studies classified and Ministry of Management in volumes segmented Environment, Policy, Strategy and types of volumes of NEMA and and Guidelines waste from waste County to include predominant Departments Menstrual sectors and of Health waste segments of management the economy (especially sources of non- biodegradable- organic- fractions, special and hazardous wastes). Document Presence of Ministry X X X X X 5M various document of Health, menstrual showing Ministry of waste the various Environment, management menstrual NEMA and innovations. waste County management Departments innovations and of Health technologies

44 Strategic Focus Area 5: Monitoring and Evaluation for Accountability and Learning Key Strategic Objective: To ensure effective monitoring and evaluation of Menstrual hygiene management interventions Expected Outcomes: ● MHM indicators developed ● MHM activities routinely measured and reported ● Fully operational and vibrant National and County MHM data and information sharing platforms ● MHM indicators included in the DHIS reporting system Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicator Develop Institute M&E system Ministry X 2M MHM specific effective M&E operationalised of Health indicators systems at all and County levels to ensure Departments coordinated of Health and sustained improvement of MHM. Promote Develop Indicators Ministry X 2M routine MHM specific developed and of Health reporting of indicators -and operationalised and County MHM activities integrate them Departments at the National into all levels of Health and County of reporting levels systems Include MHM Strengthen No. of national Ministry X 5M indicators staff capacity and Counties’ of Health in the DHIS at County, staff trained on and County reporting Inter-County use of the MHM Departments system and National M&E tools of Health level to use the MHM M&E tools in collection, collation, reporting and utilization of MHM data to inform policy changes. Encourage and Establish Ministry X 5M promote MHM mechanisms of Health research within for the and County the country collection and Departments reporting of of Health disaggregated data for decision making in MHM.

45 Key Activity Measurement Responsible Year Year Year Year Year Budget Interventions of Success/ 1 2 3 4 5 (KSHS) Indicators Mobilise Encourage key No. of MHM Ministry X X X X X 10M funding for stakeholders operational of Health MHM M&E and to conduct researches and County research operational conducted Departments researches of Health and to establish partners effective and sustainable sanitation systems in the country. Establish Fully running Ministry X 2M effective MHM system of Health Monitoring and for reporting and County evaluation (M inputs, outputs Departments & E) systems to and processes of Health monitor inputs, processes and outputs. Establish Intra- No. of MHM Ministry X 5M County, Inter- data sharing of Health County and platforms and County National MHM established Departments data review and of Health information sharing platforms

46 Roles and Responsibilities of Various Sectors on MHM Menstrual hygiene issues cut across a number of different development sectors and sub- sectors. The table below sets out the relevance of menstrual hygiene to different sectors and highlights potential key areas of responsibility. The table also identifies some of the factors that need to be considered for effective coordination and collaboration between (and within) these sectors.

Sector Responsible Link With Menstrual Key Responsibility institutions Hygiene Water, ● Ministry of Menstrual hygiene requires Incorporate menstrual Sanitation Health access to: hygiene: and Hygiene ● Ministry of ● Clean water and soap ● At different levels, (WASH) Water and for washing hands, body including service Sanitation and reusable menstrual delivery, menstrual ● Ministry of cloths. hygiene promotion, Education ● Private and hygienic capacity development and policy. ● Ministry of sanitation facilities for Environment changing and disposing ● Within approaches of sanitary protection to WASH – e.g. ● Development partners materials, and for bathing community-led total sanitation, social Private sector ● Hygiene information ● marketing, WASH in ● Menstrual waste management for disposal schools, community of cloths and pads health strategy, participatory hygiene and sanitation transformation. Health ● Ministry of ● There are health risks ● Provide accurate health associated with poor and user-friendly ● Ministry of menstrual hygiene information on the Education management that can biological facts about have health implications menstruation and ● Development Partners as a result, such as Urinary menstrual health and and Reproductive Tract hygiene. ● Private Sector Infections (UTIs/RTIs) ● Provide affordable ● Women and girls who and easy to access have menstrual disorders healthcare for and other medical menstrual health conditions may have issues, including additional needs for those caused by poor menstrual hygiene menstrual hygiene and those linked with other diseases

47 Sector Responsible Link With Menstrual Key Responsibility institutions Hygiene Education and ● Ministry of Due to challenges ● Incorporate training Health associated with MHM in reproductive health ● Ministry of learning institutions: and menstrual Education ● The rate of absenteeism hygiene into the curriculum in ● Ministry of of girls may increase, professional training Public Services, ● Cases of school drop out institutions for Youth Affairs may increase relevant sectors (e.g. and Gender Girls may experience ● WASH, protection, Development challenges in ● health, community Partners concentration, which development) may influence their performance due to ● To provide adequate stress and discomfort access to MHM products, services and If menstrual hygiene ● facilities in learning knowledge is to be institutions. mainstreamed, it needs to become a standard part of the education and training of Professionals in relevant sectors. ● There are many myths, taboos and misinformation associated with menstruation. Community ● Development ● Community development ● Facilitate linkages development Partners actors have linkages at with different ● Private sector the local level across development actors sectors that can support at the local level to ● Foreign donors menstrual hygiene address menstrual Investors ● activities. hygiene holistically. ● Relevant line ● Community development ● Support community ministries at the Programmes may enterprises to provide county level provide support to small low-cost menstrual enterprises for producing hygiene products. and distributing low ● Provide menstrual cost menstrual hygiene hygiene information products. to community organizations.

48 Sector Responsible Link With Menstrual Key Responsibility institutions Hygiene Social ● Humanitarian Women and girls in ● Ensure that women protection organizations vulnerable contexts are and girls in the most ● Development likely to face additional vulnerable situations Partners challenges in managing are supported menstruation. This includes: to manage their ● Ministry of Public Services, ● a lack of access to menstrual hygiene. Youth and products, services and ● Support those Gender Affairs facilities providing menstrual ● an unsafe environment hygiene interventions in which to manage from other sectors menstruation to identify and reach women and girls in ● forced undesirable behavior to gain access vulnerable situations. to menstrual hygiene products and services (i.e. through transactional sex). Gender This is a cross Gender power inequalities Gender advisers shall: cutting issue in decision-making, roles, ● Provide support to that needs to be and access to and control empower women addressed by all over resources can result in and girls, so that stakeholders. women and girls’ menstrual their voices are heard hygiene needs being and their menstrual overlooked or neglected. hygiene needs are taken into account. ● Engage with a range of programmes and monitor the inclusion of menstrual hygiene across sectors, promoting it where necessary Advocate for MHM to create gender equality

49 Sector Responsible Link With Menstrual Key Responsibility institutions Hygiene Private sector ● Private Sector Menstrual hygiene requires Relevant stakeholders entrepreneurs ● KEBS appropriate, affordable, should: and acceptable and accessible: ● Ministry of ● Strive to Produce and businesses Health ● menstrual hygiene distribute affordable products and appropriate MHM ● Ministry of Water and ● facilities for MHM and products and services Sanitation disposal ● Develop, monitor and control quality and ● Ministry of ● services Education These should be safety standards for accompanied by all menstrual hygiene educational materials products and disposal for correct, safe and facilities comfortable use. Employers ● Ministry of Women require access Employers to ensure and labor Labour to menstrual hygiene a menstrual hygiene- departments ● Employers products, services and friendly environment in facilities at work. the workplace. ● Workers associations ● Advocate for adequate menstrual hygiene-friendly working environment ● Create a guideline of minimum requirements for MHM in the workplace ● Incorporate MHM in the Occupational Safety and Health Act.

50 Chapter Five: Monitoring and Evaluation of the MHM Programme

Monitoring and evaluation (M&E) is integral for assessing the success of result-based programme. Stakeholders are able to learn from reported experiences, improve planning, programme implementation, define and determine allocation of resources, promote accountability, learning and basis for programme improvement. For successful implementation of this strategy, an M&E framework will be developed as an integral component to ensure the strategy objectives are achieved in a cost effective, coordinated and harmonized approach at both the national and county levels. The MHM Strategy will cover a five-year period from and will be monitored and evaluated as follows: i. The Ministry of Health, together with the MHM Task Force shall spearhead the development of MHM M&E Framework within six months of the MHM Strategy launch. The M&E framework is expected to be consistent with the tenets of the MoH Health Reporting System and have clear terms of reference for relevant stakeholders in data collection and reporting at all levels. The MHM M&E Framework shall clearly show the interplay of the MHM indicators in promoting the desired results and objectives of the MHM programme. ii. Monitoring: The National MHM Task Force shall conduct quarterly performance monitoring meetings to review progress of implementation against the results and targets, address implementation bottlenecks and if need be, recommend changes to the MHM programme. Quarterly coordination meetings will be held to review implementation and address bottlenecks. iii. Mid-Term Review: A mid-term review of the MHM Strategy shall be undertaken two years after the launch of the MHM Strategy. The mid-term review will also review performance against targets, address any constraints to implementation and refocus activities if needed. iv. Annual Review: There will be an Annual Review Report (ARR) on implementation of the strategy that will be presented to the Cabinet Secretary for Health and all the relevant stakeholders. The strategy will be reviewed periodically to address the sector challenges and emerging issues. All the relevant stakeholders will hold an annual meeting to review the progress on MHM implementation and set priorities for the coming year. v. Reporting and Feedback: The MHM reports from the Counties shall be received by the Division of Environmental Health, who are the conveners of the MHM Task Force. The reports will be presented to the MHM Task Force for analysis and consolidation to form part of the Kenya MHM quarterly report. It is expected that Counties shall send their monthly reports before the 5th day of every month. The MHM Task Force will be expected to give feedback to the counties after the analysis of the reports. The feedback will be sent to the Counties before the 15th day of every month.

51 References

Alexander, K.T, Oduor C, Odhiambo F.O, et al, Water, sanitation and hygiene conditions in Kenyan rural schools: are schools meeting the needs of menstruating girls? Water, 6: 1453-1466, 2014. Government of the Republic of Kenya (2007) Kenya Vision 2030. http://vision2030.go.ke/ inc/uploads/2018/05/Vision-2030-Popular-Version.pdf. Pg 2 Sommer M, Caruso B, Sahin M, et al, A time for global action: addressing girls’ menstrual hygiene management needs in schools. PLoS MED: 13(2) e1001962, 2016. Nyangara K. Kenya Menstrual Health Hygiene Policy: Menstrual Hygiene Management Situation Analysis Report. Maseno University, Kenya, 2016. Phillips-Howard PA, Otieno G, Burmen B, et al, Menstrual needs and associations with sexual and reproductive risks in rural Kenyan females: A cross-sectional behavioral survey linked with HIV prevalence. J Womens Health. 24(10):801-11, 2015. McMahon SA, Winch PJ, Caruso BA, et al, ‘The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya. BMC Int Health Hum Rights. 11:7, 2011. Mason L, Nyothach E, Alexander K, et al, ‘We keep it secret, so no one should know’- -a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural western Kenya. PLoS One. 8(11):e79132, 2013. Oduor C, Alexander K, Oruko K, et al, Schoolgirls’ experiences of changing and disposal of menstrual hygiene items and inferences for WASH in schools. Waterlines, 34(4),397- 411, 2015. Juma J, Nyothach E, Laserson KF, et al, Examining the safety of the menstrual cup provided to rural primary school girls in Western Kenya, BMJ Open, 0:e015429, 2017. Phillips-Howard PA, Nyothach E, Ter Kuile FO, et al, Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western Kenya. BMJ Open. 6(11):e013229,2016. Mason L, Laserson KF, Oruko K, et al, Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study. Waterlines special MHM edition, 34:1, 2015. Wilson E, Reeve J, Pitt A. Education. Period. Developing an acceptable and replicable menstrual hygiene intervention. Development in Practice, 24(1), 63-80, 2014. Sommer M, Chandraratna S, Cavill S, et al, Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries, International Journal for Equity in Health, 15:86, 2016. Callahan, R., Rademacer, K. & Wilson, L. (2015) Common Cause: Linking Menstrual Hygiene Management and Long-acting Contraception to Improve Youth Reproductive Health. https://www.twigh.org/twigh-blog-archives/2015/5/28/common-cause-linking- menstrual-hygiene-management-and-long-acting-contraception-to-improve-youth- reproductive-health

52 Rheinländer, T. and Wachira, M. (2015) Menstrual Hygiene: An ancient - but ignored Global Health problem of all women. http://www.globalhealthminders.dk/wp-content/ uploads/2015/03/GHM-MenstrualHygiene-Brief.pdf Sumpter, C., Torondel, B. (2013). A systematic review of the Health and Social Effects of Menstrual Hygiene Management, PLOS ONE, April 2013: 8:4. https://journals.plos.org/ plosone/article?id=10.1371/journal.pone.0062004 WSSCC & UN Women (2018) Menstrual Hygiene Management and Female Genital Mutilation: Case Studies in Senegal https://www.wsscc.org/wp-content/ uploads/2018/01/20171227_Policy-GHM-Senegal-EN-WEB-1.pdf PATH (2016) Girls’ and women’s right to menstrual health: Evidence and opportunities https://path.azureedge.net/media/documents/RH_outlook_mh_022016.pdf van Eijk AM, Sivakami M, Thakkar MB, et al Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis Open 2016;6:e010290. doi: 10.1136/bmjopen-2015-010290 Hennegan, J. (2016) Women and water: Menstrual hygiene management and current evidence for interventions. Global Water Forum. https://journals.plos.org/plosone/ article/file?id=10.1371/journal.pone.0146985&type=printable World Vision International (2016). Menstrual Hygiene Management. Available online: https:// www.wvcentral.org/community/wash/Pages/Menstrual-Hygiene-Management.asp

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REPUBLIC OF KENYA

MINISTRY OF HEALTH

MINISTRY OF HEALTH Division of Environmental Health

Afya House, Cathedral Road, P.O. Box 30016 001001 Nairobi Kenya Tel: +254 20 271 7077 www.health.go.ke

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